The Vistas at Oxnard Senior Living

Allegation investigated: Staff not providing adequate food service. Resident left in soiled diapers for extended amount of time. Resident needs not being met.

Licensing Program Analyst (LPA), Martha Arroyo conducted a subsequent visit to the facility to issue findings for the above allegations. The initial visit was conducted on 04/28/2023 by LPA’s T. Camara and K. Lopez a subsequent visit was conducted on 08/01/2023 by LPA M. Arroyo. During today's visit, LPA met with Interim Executive Director, Karen Enciso, and the reason for the visit was explained. Entrance interview. During the initial visit on 04/28/2023, LPA’s Camara and Lopez toured the kitchen at 10:21 a.m., toured memory care at 10:44 a.m., and reviewed and obtained copies of pertinent documents at 11:05 a.m. On 08/01/2023, LPA Arroyo conducted a plant tour at 12:56 p.m., toured memory care at 1:00 p.m., toured the kitchen/food area and dining room at 1:15 p.m., conducted interviews with the ED, two staff members, and four residents between 1:02 p.m. and 2:46 p.m., and conducted a resident file review at 3:40 p.m. and obtained copies of pertinent documents relevant to the investigation. Additionally, the LPA conducted telephonic interviews with family members on 09/29/2023 at 11:20 a.m., and 11:55 a.m., and 12:20 p.m. (Report Continued on LIC 9099C...) Unsubstantiated (Report Continued from LIC 9099...) It was alleged that staff are not providing adequate food service. It was reported that Resident #1 (R1) and others have been under fed resulting in weight loss. During the visit on 08/01/2023, the LPA observed the kitchen, food supply, monthly menu posted by the kitchen, copies of daily menu by the front desk, and random residents having lunch. The facility had a variety and adequate supply of perishable and non-perishable foods including eggs, meats, breads, canned goods, fresh fruit, fresh vegetables, and milk. Interviews conducted with residents revealed the food is good and stated snacks are passed every day around the same time. The snacks vary by days as sometimes they will get crackers, cheese, or ice cream. Interviews conducted with family members revealed that they get copies of the monthly menus from the front desk when they visit to know what the resident will be having throughout the month. Additionally, family members stated observing residents asking and receiving snacks in between meals while visiting. Furthermore, residents and family members reported having no concerns with the facility. Based on LPA observation and interviews conducted with the staff, residents, and family members, there is insufficient evidence to support the allegation of “staff are not providing adequate food service”. Therefore, this allegation is deemed Unsubstantiated at this time. It was also alleged that residents are left in soiled diapers for extended amount of time. It was reported that residents are being left in soiled diapers and residents’ beds have soiled linens. Additionally, urine stains were seen in R1’s bedsheets and R1 had to be changed several times due to R1 being wet. Information obtained and reviewed revealed that about 80% of residents in memory care are incontinent and wear diapers. Interviews conducted with residents revealed that staff are often checking on the residents throughout the day. Staff reported checking on the residents at least every two (2) hours and changing them when needed. Additionally, staff stated they have not had any family members report the residents being dirty or wet while visiting. Interviews conducted with family members revealed they often visit the residents and have not observed them being in soiled diapers. Family members stated the staff is good at changing the residents and keeping them clean. Based on the information obtained and reviewed, the Department does not have sufficient evidence to support the allegation of “residents are left in soiled diapers for extended amount of time”. Therefore, this allegation is being deemed Unsubstantiated at this time. (Report Continued on LIC 9099C...) (Report Continued from LIC 9099C...) It was further alleged that residents’ needs are not being met. It was reported that R1 has not been shaved and bathed for days at a time including brushing their teeth and laundry has not been completed for weeks. Additionally, the facility was to have a podiatrist and hairdresser come to the facility to service residents. Information obtained and reviewed revealed that residents have scheduled showers; however, residents also have the right to refuse any type of service. The end of shift report indicates how the residents interact each day. Additionally, on the narrative charting staff reported when R1 was refusing any service such as bathing and/or shaving and staff reported R1 had refused showers several times while living at the facility. Additional interviews revealed that residents will at times refuse their showers and staff will attempt to try again later the same day if not the following day. Additionally, housekeeping is done once a week for all residents in both assisted living and memory care. Per R1’s Admissions Agreement dated 01/26/2023 it states on page 7 section B that ‘personal laundry is available for an additional charge’ and on page 24 under Appendix A R1’s Power of Attorney (POA) did not indicate that they wanted additional personal laundry services added to their basic services. In addition, record review revealed that the facility places a sign-in sheet for both assisted living and memory care residents to sign up to see the Podiatrist which is scheduled to come to the facility every six (6) weeks. These sign-in sheets are available by the front desk for family members to sign up the residents from both assisted living and memory care. Furthermore, interviews conducted with residents and family members revealed they feel the facility is meeting their needs and had no concerns. Based on the information obtained and reviewed, the Department does not have sufficient evidence to support the allegation of “residents needs are not being met”. Therefore, this allegation is being deemed Unsubstantiated at this time. Exit interview conducted. No citations issued at this time. A copy of the report was provided.the state’s words, verbatim · CDSS document, Oct 30, 2023 · control 29-AS-20230427152417

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Teresa Camara conducted a case management - deficiencies visit due to a deficiency observed during the course of a complaint investigation (complaint control number 29-AS-20231012084108). LPA met with acting Executive Director (ED) Karen Enciso, LVN, and explained the reason for the visit. At 10:53 a.m. LPA reviewed and obtained pertinent records and while meeting with the ED. At 12:00 p.m. LPA observed Resident 1 (R1) in the dining room. Starting at 12:10 p.m. LPA conducted interviews with staff 1 (S1), staff 2 (S2), staff 3 (S3), and staff 4 (S4). Resident 1 (R1) was admitted to this facility in May of 2022. R1's physician report dated 5/10/2022 indicates R1 needs full assistance from facility staff for all activities of daily living: bathing, dressing, toileting, feeding and managing cash resources. R1's family manages the cash resources. During interviews with the ED and staff, they confirmed R1 needs full assistance with all R1's care needs. LPA observed R1 in the dining room during lunchtime. R1 was fully assisted with eating and drinking. LPA observed S4 cutting food, feeding R1 with a fork and picking up R1's glass which had a straw so R1 could take a drink. R1 did not handle any food, utensils, cups or glasses. During interviews with staff it was revealed R1 is unable to take their own medications. Medication Technicians must either put the medications on a spoon into R1's mouth or use a medication cup to pour the medications (pills/capsules) into R1's mouth, followed by holding a glass with a straw so R1 can take a drink. Based on the records reviewed and interviews, R1 depends on others to perform all activities of daily living and appears to need a higher level of care. The following deficiencies were observed (see LIC 809-D) and cited from the California Code of Regulations, Title 22 and California Health and Safety Code. Failure to correct the deficiencies may result in civil penalties. Exit interview conducted. A copy of the report and appeal rights were provided.the state’s words, verbatim · CDSS document, Oct 19, 2023

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87615 · Plan of correction due date: Oct 24, 2023

87615 Prohibited Health Conditions (a) Persons who require health services for or have a health condition including, but not limited to, those specified below shall not be admitted or retained in a residential care facility for the elderly: (5)Residents who depend on others to perform all activities of daily living for them as set forth in Section 87459, Functional Capabilities. This requirement is not met as evidenced by: The facility did not comply with the section cited above as staff must perform all activities of daily living for R1, which poses an immediate health and safety risk to person in care.the state’s words, verbatim · CDSS document, Oct 19, 2023

Plan of correction: The ED will notify R1 and R1's representatives by 10/24/2023 of R1's need for a higher level of care and provide a copy of the notification to CCL by that date.

Allegation investigated: Staff did not receive proper training

Licensing Program Analyst (LPA) Teresa Camara conducted a subsequent complaint investigation visit to the facility. LPA met with acting administrator Karen Enciso, LVN, and explained the reason for the visit. Allegation: Staff did not receive proper training This allegation was regarding staff not being trained to assist with administering oxygen. LPA interviewed S1 who confirmed they did not receive training on oxygen administration. S1 confirmed that one night they were expected to assist a resident with their oxygen but S1 did not have training to do so and neither did any of the other staff on that PM shift. Therefore, the allegation staff did not receive proper training is deemed Substantiated at this time. The following deficiency was observed (See LIC 809-D.) and cited from the California Code of Regulations, Title 22 and California Health and Safety Code. Failure to correct the deficiencies may result in civil penalties. Exit interview conducted and a copy of the report and appeal rights provided. Substantiated (continued from 9099-A) this with Ventura County Public Health (VCPH), and they told her mass testing was not necessary. LPA confirmed with VCPH that this information is correct. It would be reasonable to do focus testing if contact tracing found others who may have been exposed during the contagious period. In order to best utilize resources, if it is reasonable to surmise others were not exposed during the contagious period then testing was not warranted. The contagious period is considered to be 48 hours prior to testing positive or onset of symptoms. Therefore, the allegation is deemed Unsubstantiated at this time. Allegation: Facility did not notify residents and/or responsible parties timely of COVID-19 outbreak This allegation specifically referred to June of 2022 when two residents and one staff tested positive for COVID-19. LPA discussed this case with the administrator at the time, Kortnie Spitznogle. After the administrator discussed the cases with VCPH, it was determined this was not considered an outbreak and it was not necessary to close down the dining room or activities or do mass testing. Therefore, she did not need to notify residents/families of an outbreak since it was not considered an outbreak. Later, in July 2022, there was an outbreak in the facility and the administrator conducted testing as per VCPH guidance, shut down activities and the dining room, and contacted residents and families. Based on this information, the allegation is deemed Unsubstantiated at this time. Staff who tested positive for COVID-19 told to report to work This allegation was regarding a staff being told to report to work after testing positive for COVID-19. LPA attempted to contact this staff by phone three times. This staff no longer works at this facility nor is this staff currently associated with any other assisted living facility. The licensee’s human resources department provided information on this staff’s dates of work. This staff was not present in the facility for seven days after testing positive for COVID-19; staff last worked 6/12/2022, tested positive 6/16/2022 and did not return to work until 6/23/2022. At that time, Public Health recommended if staff were feeling better and not running a fever (without fever reducing medications), they could return to work after five days of testing positive. Therefore, this allegation is deemed Unsubtantiated at this time. (continued on 9099-C) (continued from 9099-C) Allegation: Assisted Living left unattended by staff This allegation was regarding two assisted living staff leaving the building to follow a resident next door to the 7-11 convenience store to prevent the resident from purchasing alcohol. LPA attempted to contact the two staff who allegedly left assisted living unattended. Neither of these two staff still work at the facility nor are they associated to any other assisted living facility. LPA tried contacting these staff by phone and by email on three separate dates, however staff did not respond. LPA spoke with another staff (S1) who stated it is possible staff left to chase after a resident who would leave the facility to go next door to the 7-11 convenience store to purchase alcohol. However, S1 also stated the walkie talkies work at 7-11. In addition, walkie talkies announce to all staff at the facility if a resident is calling for assistance. LPA was unable to confirm if assisted living residents were left unattended. Therefore, this allegation is deemed Unsubstantiated at this time.the state’s words, verbatim · CDSS document, Sep 27, 2023 · control 29-AS-20220718090048

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87618(b)(2) · Plan of correction due date: Oct 4, 2023

87618 Oxygen Administration - Gas and Liquid (b) In addition to Section 87611(b), the licensee shall be responsible for the following: (2) Ensuring that oxygen administration is provided by an appropriately skilled professional should the resident require assistance. This requirement was not met as evidenced by: Based on interviews, the licensee did not comply with the section cited above as the facility failed to ensure staff were trained to assist resident with oxygen administration, which posed a potential health & safety risk to residents in care.the state’s words, verbatim · CDSS document, Sep 27, 2023

Plan of correction: The acting administrator agreed to submit a plan on how the facility will ensure there is oxygent administration trained staff on each shift when there are residents in the facilty on oxygen. The plan will be submitted to CCL on or before 10/4/2023.

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Kelly Dulek conducted a case management visit to address deficiencies observed during a facility tour conducted at the facility today. LPA arrived at the facility at 04:19PM and met with Maintenance Director Richard Lee. Entrance interview conducted. During today's visit, LPA interviewed Maintenance Director at 04:22PM and throughout the visit and toured the facility with Maintenance Director at 04:48PM. LPA reviewed the facility's Guardian roster and observed that Staff #1 (S1) has been employed at the facility since 03/10/2023 and does not currently have fingerprint background clearance. The following deficiency was observed (See LIC 809-D) and cited from the California Code of Regulations, Title 22 and/or California Health and Safety Code. Civil penalty issued in the amount of $500. Failure to correct the deficiency may result in additional civil penalties. Exit interview conducted. A copy of the report and appeal rights were provided.the state’s words, verbatim · CDSS document, Sep 18, 2023

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87355(e)(1) · Plan of correction due date: Sep 19, 2023

87355 Criminal Record Clearance (e) All individuals subject to a criminal record review...shall prior to working, residing or volunteering in a licensed facility: (1) Obtain a California clearance or a criminal record exemption as required by the Department or This requirement is not met as evidenced by: Based on interview and record review, the licensee did not comply with the above cited section, as Staff #1 does not have criminal record clearance and has been employed in the facility since 03/10/2023, which poses an immediate safety risk to persons in care.the state’s words, verbatim · CDSS document, Sep 18, 2023

Plan of correction: Facility designee agreed to coordinate with the corporate management and ensure S1 receives background clearance as required. Designee and/or corporate will contact CCLD with a staffing plan to comply with this regulation by POC due date.

Allegation investigated: Personal protective equipment (PPE) was not worn and/or not worn properly during COVID-19 outbreak

Licensing Program Analyst (LPA) Teresa Camara conducted a subsequent complaint investigation visit. LPA met with acting Resident Care Director (RCD) Joe Allen Cruz, RN. Cruz is from the corporate office and is currently filling in as RCD until a new RCD is hired. The facility currently does not have a permanent administrator. The interim administrator/executive director is Karen Enciso, LVN, whose first day was supposed to be today but she is out sick. Regarding the allegation staff were not properly wearing PPE during a COVID-19 outbreak, LPA had visited the facility on 7/22/2022, and observed staff wearing masks pulled down below their noses. This timeframe was during an outbreak at the facility. In addition, facilities were still mandated to have staff wear masks at that time. Based on this information, the above noted allegation is deemed Substantiated at this time. Per the California Code of Regulations (CCR), Title 22, Division 6, Chapter 8, the following deficiencies are cited: (Refer to LIC 9099-D). Exit interview conducted. Report and appeal rights were issued. Substantiated (continued from 9099-A) Initially R1 was receiving the medication at 8:00 a.m. and the time of day was changed to 7:00 p.m. on 6/20/2022. The RCD stated medication time frames for dispensing can be as early as one hour before or as late as one hour after the stated time. Since R1's prescription did not indicate the time of day it should be given, the time of day may have been based on R1's preference. A review of records showed that R1 was given the medication daily by staff except for 7/1/2022 where notes indicate the medication was provided to a family member to give to R1 and on 7/4,5,6,7,8/2022 where notes indicate R1 was out of the facility. There were no records indicating R1 missed the medication while at the facility. Based on these records, the allegation staff was not administering the medication is deemed Unsubstantiated at this time. Exit interview conducted and report issued.the state’s words, verbatim · CDSS document, Sep 14, 2023 · control 29-AS-20220718090048

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(2) · Plan of correction due date: Sep 28, 2023

87468.1(a)(2) Personal Rights of Residents in All Facilities ...To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement was not met as evidenced by: Based on observations, the licensee did not comply with the section cited above, as staff were not properly wearing face masks in the facility, which posed a potential personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Sep 14, 2023

Plan of correction: The RCD agreed to conduct training with all staff about proper mask-wearing and COVID-19 prevention protocol. Evidence of training will be provided to CCL on or before 9/28/2023.

The state marks this report as 5 pages; the online copy we transcribed has 4. You can request the full file from the county licensing office.

Allegation investigated: Facility does not have an adequate Emergency Disaster Plan. Staff are not adequately trained in the event of an emergency.

Licensing Program Analyst (LPA) Teresa Camara conducted an intial complaint investigation visit. LPA met with executive director/administrator Elizabeth Whittington and explained the reason for the visit. At 9:30 a.m. LPA conducted an interview with the administrator. At 10:58 a.m. LPA reviewed and obtained pertient documents. Administrator showed LPA sign in sheets and agendas for all staff training conducted monthly. During the all staff (all shifts) training they go over emergency procedures for different emergency scenarios. These trainings are conducted monthly. (continued on 9099-C) Substantiated (continued from 9099) The most recent emergency procedure drill was conducted on 7/11/2023 when the facility's smoke alarm was triggered due to a resident burning something in their microwave. The administrator stated she looked at the fire panel and saw that smoke was detected so she went through with a full evacuation of the facility because at the moment she did not know what was causing the smoke. Memory care residents were evacuated to the patio area where staff made sure they stayed in the shade and stayed hydrated. All assisted living residents were evacuated to the front of the building and were kept in the shade and hydrated. Many of the residents were already downstairs but those who needed to evacuate from the second and third floor used the stairs. There was one resident on the second floor who was not able to evacuate down the stairs and staff were not confident in how to use the evacuation chair in the stairwell. The administrator stated the resident was kept at the top of the lobby stairs with a staff member. In the event of an actual emergency the fire department personnel would have immediate access to the resident so they could assist the resident in evacuating. LPA reviewed the facility's Emergency Action Plan and found it to be very comprehensive, however the facility needs to update emergency contact numbers for facility personnel and they need to post the information in the facility as well as provide an updated copy to Licensing. Allegation: Facility does not have an adequate Emergency Disaster Plan. LPA reviewed records and found that while the facility has a comprehensive Emergency Action Plan they have not updated/posted the personnel names and their emergency phone numbers since 2018. There have been several staffing changes since then and the emergency staff contacts are outdated. Therefore, this allegation is deemed Substantiated at this time. Allegation: Staff are not adequately trained in the event of an emergency. The administrator stated that facility staff require training on use of the evacuation chair in the stairwell. The fire department gave the administrator a number to call to set up the training with them. This allegation is deemed Substantiated at this time. The following deficiencies were observed (see LIC 9099-D) and cited from the California Code of Regulations, Title 22 and California Health and Safety Code. Failure to correct the deficiencies may result in civil penalties. Exit interview conducted. A copy of the report and appeal rights were provided via email.the state’s words, verbatim · CDSS document, Aug 10, 2023 · control 29-AS-20230803162328

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569.695(b) · Plan of correction due date: Aug 17, 2023

§1569.695 Emergency Plans (b) A facility shall provide training on the plan to each staff member upon hire and annually thereafter. The training shall include staff responsibilities during an emergency or disaster. This requirement is not met as evidenced by: The facility did not comply with the section cited above as the facility staff have not been trained on how to use the evacuation chair in the stairwell which poses a potential health and safety risk to person in care.the state’s words, verbatim · CDSS document, Aug 10, 2023

Plan of correction: The administrator will contact the fire department to set up training for staff on how to use the evacuation chair. Administrator will provide the training date to CCL by 8/17/23 and a copy of the sign-in sheet once the training is completed.

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569.695(d) · Plan of correction due date: Aug 17, 2023

§1569.695 Emergency Plans (d) A facility shall review the plan annually and make updates as necessary, including changes in floor plans and the population served. The licensee or administrator shall sign and date documentation to indicate that the plan has been reviewed and updated as necessary. This requirement is not met as evidenced by: The facility did not comply with the section cited above as the facility staff and their emergency contact numbers have not been updated which poses a potential health and safety risk to person in care.the state’s words, verbatim · CDSS document, Aug 10, 2023

Plan of correction: The administrator will review the facility's emergency plans and make any necessary updates, including emergency staff contact information. Administrator will provide an updated LIC610E to CCL by 8/17/2023.

Allegation investigated: Staff not communicating with authorized representative in a timely manner

Licensing Program Analyst (LPA) Angel Ascencio arrived at the above facility to deliver findings. LPA Ascencio met with Executive Director (ED) Elizabeth Whittington at 09:30 a.m. Entrance interview conducted. On 04/20/2022, the Department received a complaint alleging that staff is not communicating with authorized representative in a timely manner. Interview with ED Kortnie Spitznogle, on 04/25/2022 starting at 10:10 a.m. revealed that R1’s family member calls the facility various times of the week and expect answers immediately. There have been a number of occasions that R1’s family member curses and yell at facility staff because R1’s family member cannot reach the ED. ED Spitznogle added that they attempt to return the call in a timely manner but because of the needs of the facility, ED Spitznogle returns the call at a later time, 2-5 days after the initial call. Interview with R1’s Family Member on 05/04/2022 revealed that ED Kortnie Spitznogle does not return calls or does not reply to emails timely. Continued on LIC- 9099 C Page 1 Substantiated Additionally, R1’s family member indicated that it would take days or even weeks for the ED to return the call, despite R1’s family member calling daily. At one point, R1’s family member mailed a certified letter to ED Spitznogle requesting additional information regarding rent increase and packages. R1’s family member stated after a certified mail was delivered on 04/12/2022, they received an email on 04/26/2022 by ED Spitznogle. Email conversation, on 07/11/2022, between R1’s family member and ED Spitznogle indicated that ED Spitznogle was reaching out to R1’s family member due to ED Spitznogle receiving a certified letter, while R1’s family member indicated that the letter was delivered on 04/12/2022 and it took more over a week for ED Spitznogle to get back to them. Fifteen (15) days would pass before the email was sent by ED Spitznogle. Additionally, another email was observed, dated on 04/29/2022 from R1’s family member requesting a call from ED Spitznogle. A continuation of that email revealed that on 05/03/2022, a telephone call was conducted between ED Spitznogle and R1’s family member. Four (4) days after requesting to chat with the ED. A review of the California Code of Regulations, Title 22, 87468.1 Personal Rights of Residents in All Facilities, indicates that: (a) Residents in all residential care facilities for the elderly shall have all the following personal rights: (9) To have communications to the licensee from their representatives answered promptly and appropriately. Promptly, meaning immediately or without delay. Even though R1’s family member requested to speak to the ED on various occasions, ED Spitznogle returned the family members request by a call or email. However, based on the Title 22 regulation, ED Spitznogle did not promptly and appropriately communicate with the R1’s family member as various days passed before a response was generated by ED Spitznogle. Thus, the allegations, staff is not communicating with authorized representative in a timely manner is deemed substantiated at this time. 1 Citation was issued today. Per the California Code of Regulations (CCR), Title 22, Division 6, Chapter 8, the following deficiencies are cited: (Refer to LIC 9099-D). Exit interview conducted and a copy of the report and appeal rights were issued to ED Whittington. File review also revealed no documentation within home health, hospice and facility notes indicating the necessity of podiatry services. Interview with a podiatry Health Service Coordinator, on 06/29/2023, starting at 1:54 p.m., revealed that R1 was seen by the podiatrist on two (2) separate occasions: once (1) on 03/11/2021 and another on 06/05/2022. That same day, interview with a hospice representative, at 2:15 p.m., revealed that although a resident can be on hospice services, podiatry care is a service not offered under hospice care. If the resident requires podiatry services, the hospice agency will reach out to a podiatrist. Also, that same day, interview with Staff #1 (S1), starting at 2:35 p.m. confirmed what hospice representative stated. In addition, S1 added that if a resident is not on hospice services, Pacifica will reach out to a podiatrist to come out and provide services. On 07/11/2023, a review of Pacifica’s Admission Agreement form indicated that on page four (4), section J. Observation and Consultation: The staff at the Community will observe your health status to identity your dietary, social, and health care needs and will provide you with the consultations regarding social and health-related issues. The community will notify family, responsible parties and other appropriate persons and/or agencies of your significant needs. Additionally, Section II. Personal Assistance and Care, on page six (6) indicated that: We will also assist you, as needed, with the scheduling of medical and dental appointments and with accessing community resources and transferring to outside facilities, as needed and prescribed by your primary physician. Although there was a significant time gap between podiatry services for R1, 03/22/2021 and 06/05/2022, review of home health, hospice and facility documentation did not indicate that R1 needed podiatry services. Based on information gathered, there is insufficient evidence to support the claim that staff are not providing adequate care to resident in care. The allegation is deemed unsubstantiated at this time. LPA Ascencio spoke with ED Whittington regarding the Admission Agreement policies and reiterated the importance to observe a resident’s health status needs and provide consultation on those issues and notifying the appropriate persons or agency. Exit interview conducted and a copy of the report was issued to ED.the state’s words, verbatim · CDSS document, Jul 11, 2023 · control 29-AS-20220420082532

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(9) · Plan of correction due date: Jul 21, 2023

87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights:(9) To have communications to the licensee from their representatives answered promptly and appropriately. This requirement is not met as evidence by: Based on interviews and documentation the licensee did not comply with the section cited above as ED Spitznogle did not communicate with R1's family member promptly with poses a potential health, safety and personal rigths violation to person in care.the state’s words, verbatim · CDSS document, Jul 11, 2023

Plan of correction: ED will design a plan to effectively communicate with family members and the time frame of that communication. Plan will be send to CCL by 07/21/2023.

Allegation investigated: Resident develop pressure sores while in care. Resident not being provided their deliveries.

Licensing Program Analyst (LPA) Angel Ascencio arrived at the above facility to deliver findings. LPA Ascencio met with Executive Director (ED) Elizabeth Whittington at 12:10 p.m. Entrance interview conducted. On 04/20/2022, the Department received a complaint alleging that resident developed pressure sores while in care and resident not being provided with deliveries. Interview with Administrator Kortnie Spitznogle, on 04/25/2022 starting at 10:10 a.m. revealed that Resident #1 (R1) moved into the facility on 05/20/2020. At the time of admission, R1 did not has pressure injuries, but there was a time that R1 did have pressure injuries. Over that time, we have worked very hard with the hospice agency to get R1’s pressure injury under control and it’s worked. R1 did have pressure injuries last year, but not anymore. R1 refuses to get out of the bed. R1 eats, sleeps, and gets a bed bath, all while in bed. Continued on LIC 9099 - C Page 1 Unsubstantiated That same day, interview with R1, starting at 12:32 p.m., revealed that they are on hospice and are assisted with their needs daily by the hospice company and the caregivers at the facility. Additionally, R1 added that they do need get up from bed due to having bad legs, knees, and lower back pain. It is much more comfortable to be in bed. Also, that same day, interview with Hospice Nurse, starting at 12:45 p.m. revealed that in December of 2021, R1 had a stage II/stage III pressure injury on their coccyx area. Additionally, R1 was admitted on 05/18/2021, on hospice services with a diagnosis of Congestive Heart Failure (CHF), Stage 3 Pressure injury and 3 other medical conditions. Hospice Nurse added that R1 does not like to get out of bed, refuses to get out of bed, thus resulting in this injury on R1’s coccyx. However, with the help of the facility caregivers, and with our hospice team, we were able to heal R1’s pressure injury. At this moment in time, there is no injury. Hospice Nurse added they do not feel the facility was at fault for R1’s pressure injuries as it was known to hospice and facility staff workers that R1 refused to get out of bed and refused care. Lastly, Hospice nurse indicated that although the facility staff stated that repositioning is a service that only a skilled nursing facility (SNF) conducted and not at an assisted living facility, R1 was repositioned every two (2) hours, per recommendation from the hospice Nurse and hospice care plan. On 06/29/2023, LPA Ascencio conducted a file review for R1 confirming what the Hospice Nurse indicated. Additionally, on 05/21/2021 through 04/04/2022, hospice notes revealed that R1 sustained either a stage 2, stage 3 or unstageable pressure wound in the coccyx area during these time periods. In addition, further review of R1’s file indicated that on 05/22/2020 an initial Home Health assessment was conducted based on MD order from a hospitalization prior to the admission at Pacifica Senior Living. Additionally, Home Health notes revealed that on 05/26/2020, facility staff informed home health of an early-stage skin breakdown at coccyx and encouraged facility staff to turn in bed every 2 hours. Home health notes from 05/27/2020 and 05/28/2020 indicates “patient refused to get out of bed. Patient with wound to coccyx” and “patient finally agreed to get out of bed…fear of falling when sitting on the edge of the bed.” Interview with Home Health Nurse on 06/29/2023, starting at 2:30 p.m. revealed that they assisted R1 various times in changing their wound at Pacifica. Home Health Nurse indicated R1 stayed mostly in their bed, and that the facility did assist R1 in bed and did their best to they could reposition them. Continued on LIC 9099 - C Page 2 Although R1 did develop pressure sores while in care, home health nurse, hospice nurse and documentation revealed R1 was being assisted in all aspect of daily living, in addition to addressing the wound on R1’s coccyx and repositioning R1 every 2 hours. Interviews and documentation collaborated that the facility did not neglect R1, and that the facility was not at fault for R1 developing pressure injuries and instead showed that R1 assessed their right to refuse and stay bed. Based on evidence gathered throughout the investigation, there is insufficient evidence to support the allegation that resident developed pressure sores while in care. Lastly regarding the allegation, resident not being provided with deliveries. Interview with R1’s Family Member on 05/04/2022 revealed that they have been shipping packages over to R1 since admission. R1 Family Member stated they send over adult briefs, wipes, utensils, plates, and telephones for R1, who indicated they do not receive the items. R1’s Family Member indicated sending emails and requested calls from the facility requesting confirmation of the packages being accepted and delivered to R1. Lastly, R1’s Family Member indicated that there have been times they did call and sent me an email confirming the packages but after I talked to Executive Director (ED) Kortnie Spitznogle, we came up with a plan keep me informed of the packages. So far, the plan is working. Interview with ED Spitznogle on 04/25/2022 revealed that all packages received at the facility are documented and then sent over to the resident’s room. With the case of R1, because they are forgetful and bed bound, when packages get delivered to R1’s room, staff place the items in a location unknown to R1, causing confusion. ED Spitznogle stated they have spoken to R1’s Family Member on various times regarding “lost” or “missing” items but they are not, they are in R1’s room, in a closet or cabinet. On 06/29/2023, LPA Ascencio received Daily Delivery Logs for January 2022, February 2022, and April 2022. Delivery logs indicated the facility receiving packages and R1 accepting those packages from staff when brough to their room. Also, LPA Ascencio received various email corresponding to R1’s Family Member from the front desk, Business Office Manager or ED regarding the acceptance of packages and confirming the deliveries of those packages to R1. Interviews with various residents on 04/25/2022, 05/03/2023 and 05/05/2023 revealed that residents have not been missing any packages. In addition, resident obtain their packages from the front desk, or they are delivered to their rooms by the staff. Lastly, interviews with residents revealed that there have never been any issues with being provided deliveries. Based on evidence gathered, there is insufficient evidence to support the claim that the resident is not being provided with deliveries. Exit interview conducted and a copy of the report was issued. Page 3the state’s words, verbatim · CDSS document, Jul 10, 2023 · control 29-AS-20220420082532

The state marks this report as 4 pages; the online copy we transcribed has 3. You can request the full file from the county licensing office.

Allegation investigated: Staff neglected resident while in care

Licensing Program Analyst (LPA) Elsie Campos arrived unannounced to conduct a subsequent complaint visit. The LPA met with Executive Director Elizabeth Whittington and explained the reason for the visit. Allegation: Staff neglected resident while in care It was alleged that staff were to check on Resident #1 (R1) every two hours, along with daily bath and dressing assistance. It was further alleged that no one came to check on R1 from 3:00 p.m. until 10:00 p.m. on the day R1 arrived at the facility. It was alleged that staff were seen and heard in the hall laughing, talking about needing a nap, but allegedly never came to R1’s room or came to check on R1 during the night. Interviews with staff did not deny claims that they talk in the hallways however denied that personal interactions interfere with resident care. Interviews with staff further revealed that R1 was only in the facility for less than12 hours and was only at the facility around dinner hours up until the beginning of breakfast hours. **Continued on LIC 9099-C** Unsubstantiated It was further mentioned that because R1 was settling in and was accompanied by family staff do not custom not to interfere unless requested by family to come in. Staff were not briefed to check on R1 throughout the first night as R1 had just arrived at the facility and was getting comfortable with family. Interviews with staff confirmed staff are normally notified of new residents before starting a shift so they can accommodate any of their needs. Information obtained from interviews with residents, staff and witnesses did not corroborate claims that staff neglect residents while in care. Resident interviews communicated no concerns regarding care or not having their needs met and indicated that staff are responsive to their needs. Staff confirmed that any special instructions for R1 were in place and that R1 was only in the facility for a short period of time which may have interfered with the facilities ability to follow through on R1 needs and services plan on the day of arrival. Based on the information obtained, there is insufficient evidence to support the claim that the facility staff neglected resident while in care. The allegation is deemed Unsubstantiated at this time.the state’s words, verbatim · CDSS document, Jul 10, 2023 · control 29-AS-20230427100226

Allegation investigated: Staff failed to provide adequate food service

Licensing Program Analyst (LPA) Elsie Campos arrived unannounced to conduct a subsequent complaint visit. The LPA met with Executive Director Elizabeth Whittington and explained the reason for the visit. Allegation: Staff failed to provide adequate food service It was alleged that the quality of the food the facility serves to the residents is poor as it is served cold. Interviews with R1’s family member revealed that the food served to R1 was cold however it was not at the fault of the kitchen as the only food item they were able to offer at the time due to kitchen after hours was a hot dog which they heated up in R1’s room microwave. Morning food service was claimed to not be completed for R1 however interviews with staff revealed that R1 was only in the facility for less than 12 hours and was only at the facility after dinner hours up until the beginning of breakfast hours. Interviews with staff confirmed that in room breakfast service begins anywhere between 8 and 8:30 a.m. and room service is not always done before dining room service. **Continued on LIC 9099-C** Unsubstantiated Interviews with family claimed that they went down to the dining area to request breakfast at 8:30 a.m. at which time breakfast was just starting distribution. Information obtained from interviews with residents, staff and witnesses did not corroborate claims that food served at the facility was of poor quality nor an insufficient amount. Resident interviews communicated no concerns regarding food service and that they do receive their meals timely and in good quality. Staff confirmed that any special instructions for R1’s meal service were in place and that R1 was only in the facility for a short period of time which may have interfered with the facilities ability to follow through on R1’s meal service. LPA additionally observed the kitchen which had sufficient food items and were observed to be in good condition. Kitchen staff interviews revealed that there are additional food items available for residents after kitchen hours however those items offered are usually not hot items such as sandwiches and fruit, unless it is something that can be heated up easily in a microwave such as a hot dog. Based on the information obtained, there is insufficient evidence to support the claim that the facility failed to provide adequate food service. The allegation is deemed Unsubstantiated at this time.the state’s words, verbatim · CDSS document, Jul 7, 2023 · control 29-AS-20230427100226

The state marks this report as 3 pages; the online copy we transcribed has 2. You can request the full file from the county licensing office.

Allegation investigated: Staff are hitting resident Staff are not safeguarding resident's personal belongings Staff yell at resident Staff are mismanaging resident's medication

Licensing Program Analyst (LPA) Angel Ascencio conducted a subsequent visit to the above facility to deliver findings. LPA Ascencio met with Executive Director (ED) Elizabeth Whittington at 09:50 a.m. Entrance interview conducted. On 12/10/2021, the Department received a complaint alleging that staff are hitting residents, staff are not safeguarding resident’s personal belongings, staff yell at resident and staff are mismanaging resident’s medication. On 12/13/2021, starting at 12:25 p.m., LPA Ascencio conducted an interview with Staff #1 (S1). Interview with S1 revealed that they have not heard of any staff hitting residents. Additionally, S1 added that during their training, one of the topics for training is Elder Abuse and how to report it. Later that same day, interview at 1:30 p.m., with Resident #1 (R1) on 12/13/2021 revealed that they have not been hit by staff but instead are pushed by staff members when they are assisting R1 with their activities of daily living (ADL). Additionally, R1 stated that staff members rush R1 and are not sensitive to R1’s mobility. Continued on LIC 9099 - C Page 1 Unsubstantiated Interview with various staff members on 03/01/2023, starting at 12:35 p.m. revealed that they have not seen or heard of any residents being physically abused by staff members. Staff stated that if they were to observe or hear of any physical abuse, they would the Ombudsman hotline, Community Care Licensing (CCL), and let their supervisor know. Lastly, staff interviews indicated that although some residents are difficult to manage, staff take their time to help with their needs and ADL’s. On 05/03/23, starting at 2:30 p.m. and on 05/05/2023, starting at 11:08 a.m., interview with residents revealed that no staff has hit them during care. Additionally, resident interviews added that the staff are nice, polite, and very professional when assisting residents. Based on the evidence gathered throughout the investigation, there is insufficient evidence to support the allegation that staff are hitting residents. Thus, the allegation is deemed unsubstantiated at this time. Regarding the allegation of staff are not safeguarding resident's personal belongings. Interviews with residents on 12/13/2021 starting at 1:30 p.m., and on 05/05/2023, starting at 11:08 a.m., revealed that they have not had any personal belongings missing from their apartments. Additionally, residents stated leaving various items of value in their room and had not had any problems with them being lost of stolen. Interview with R2, on 05/03/23, starting at 2:30 p.m. revealed that a missing bottle of moisturizer had gone missing at one point and was never found. Interview with R3, on 05/05/2023, starting at 11:26 a.m. revealed that they had about $80.00 cash in a wallet on their countertop that was missing. R3 added that they could not remember the exact date but was sure there was $80.00 in their wallet. Either way, R3 did not want to report it to management or police enforcement and stated to “forget about it”. Interview with staff members on 12/13/2021, starting at 12:25 p.m., and on 03/01/2023, starting at 12:35 p.m. revealed that they have not seen or heard of any personal belonging from resident that have gone missing, lost or stolen. Additionally, staff stated that resident misplace their personal belonging throughout the facility and forget where they place those items. Residents are quick to assume their items were stolen by staff. Once the item is found, the residents are happy their belongings have returned. Although staff interviews stated that they have not heard of any personal belongings of residents that have been stolen, staff indicated that residents misplace items which are found by staff within a few days. Additionally, interviews with R2 revealed that a moisturizer was missing while R3 stated that $80.00 was missing from their wallet. Continued on LIC 9099 - C Page 2 Both R2 and R3 indicated they did not want to pursue any formal complaint regarding the missing items. Although the allegations may have happened, there is insufficient evidence to support the allegation that staff are not safeguarding the resident’s personal belongings. LPA Ascencio spoke with Administrator Elizabeth Whittington regarding residents missing items. Administrator Whittington stated they will conduct staff training on safeguarding personal belonging to prevent any future incidents. Regarding the allegation staff are yelling at residents. Interviews with residents on 12/13/2021 starting at 1:30 p.m., 05/03/23, starting at 2:30 p.m. and on 05/05/2023, starting at 11:08 a.m., revealed that staff have not yelled or screamed at residents while in care. Additionally, residents stated that most staff members are very nice, and professional who are willing to go out of their way to help residents out. Residents added that there are times staff speak a bit loud that it can be mistaken as yelling, but no yelling occurs. Lastly, resident interviews added that although most staff members are good, but there are some staff who come in, do their job and leave, not putting in the extra effort for us residents. Interview with staff members on 12/13/2021, starting at 12:25 p.m., and on 03/01/2023, starting at 12:35 p.m. revealed that they have not seen or heard of any staff member yelling at residents while in care. Additionally, staff stated that they speak to resident loudly for them to hear but not yell at residents. Thus, based on evidence gathered throughout the investigation, there is insufficient evidence to support the claim that staff are yelling at residents. Lastly, regarding the allegation of staff are mismanaging resident’s medication. Interviews with residents on 05/03/23, starting at 2:30 p.m. and on 05/05/2023, starting at 11:08 a.m., revealed that some residents manage their own medication while other residents are helped with the self-administration of medication by the facility staff. Those residents who the facility staff assist with self-administration of medication, revealed that their medication has never been missed, arrives on time and is always available if needed. On 06/20/2023, starting at 01:10 p.m., a medication audit was conducted for residents R1, R4 and R5. Medication audit revealed that R1, R4 and R5 have a current supply of routine and “as needed” (PRN) medication for anxiety. Thus, based on the interviews and medication audit, there is insufficient evidence to support the allegation of staff are mismanaging resident’s medication. The allegation is deemed unsubstantiated at this time. Exit interview conducted and a copy of the report was issued to ED Whittington. Page 3the state’s words, verbatim · CDSS document, Jun 20, 2023 · control 29-AS-20211210101025

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Angel Ascencio conducted a a Case Management – Deficieny visit to the above facility. LPA Ascencio met with Executive Director (ED) Elizabeth Whittington at 09:10 a.m. During today’s visit, while on a facility tour at 09:31 a.m. , LPA Ascencio observed an unlocked kitchen door, in the memory care unit, that contained unknown chemicals accessible to residents in care. Staff immediately secured door to the dinning room making chemicals inaccessible. Additionally, at 09:45 a.m., LPA Ascencio observed unknown chemicals (disinfectant cleaner) in an unlocked staff lounge accessible to resident in care. At 09:46 a.m., during a tour in the staff lounge, LPA Ascencio observed two (2) knifes accessible to resident while in care. Staff secured the items in a locked location. Two (2) citation were issued today. The following deficiencies were observed (See LIC 809-D.) and cited from the California Code of Regulations, Title 22 and California Health and Safety Code. Failure to correct the deficiencies may result in civil penalties. A copy of the report and appeal right were issued to ED Whittington.the state’s words, verbatim · CDSS document, Jun 20, 2023

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87705(f)(2) · Plan of correction due date: Jun 22, 2023

87705 Care of Persons with Dementia (f) The following shall be stored inaccessible to residents with dementia: (2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants. This requiement is not met as evidenced by: Based on observation, the licensee did not comply with the section cited above as unknown chemicals and disinfectant spray was observed in a kitchen and staff lounge accessible to residents which poses/posed an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jun 20, 2023

Plan of correction: Staff placed items in a secure location while on tour with LPA. Administrator will have outside agency conduct training on section 87705 and submit documentation to CCL by 06/22/23.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87705(f)(1) · Plan of correction due date: Jun 22, 2023

87705 Care of Persons with Dementia (f)The following shall be stored inaccessible to residents with dementia (1) (1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s). This requiement is not met as evidenced by: Based on LPA observation the licensee did not comply with the section cited above as kitchen knifes were in an unlocked staff lounge accessible to residents which poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jun 20, 2023

Plan of correction: Staff placed items in a secure location while on tour with LPA. Administrator will have outside agency conduct training on section 87705 and submit documentation to CCL by 06/22/23.

Allegation investigated: Facility is unclean Staff failed to provide a comfortable environment for residents Staff failed to issue a refund

Licensing Program Analysts (LPAs) Ashley Smith and Elsie Campos arrived unannounced to conduct a subsequent complaint visit. The LPAs met with Executive Director Elizabeth Whittington and explained the reason for the visit. Today, the LPAs toured the facility, conducted four (4) staff interviews from 10:00 a.m. - 11:15 a.m., and seven (7) resident interviews from 12:00 p.m. – 1:15 p.m. The LPA’s also interviewed two (2) resident responsible parties at 10:40 a.m. and 11:16 a.m. In addition, the LPAs reviewed records pertinent to the investigation. CONT 9099-C Unsubstantiated Page 2 Allegation: Facility is unclean It is alleged that upon move in, Resident #1's (R1) room was unclean. It was further alleged that R1’s cupboards and drawers were not cleaned out, and R1’s refrigerator was not cleaned out. Interviews with care staff and housekeeping staff supported claims that upon notification of a new resident move in, rooms are appropriately cleaned to prepare for the new admit. Staff whom were present in the room denied claims that R1’s room was unclean, yet admitted that there were items found in R1’s drawers. However, staff contacted housekeeping, whom immediately responded and ensured that all drawers were fully cleaned out. Information obtained from resident interviews denied claims that rooms were unclean, and it was noted that housekeeping staff are responsive in ensuring that rooms were tended to on a weekly, or as-needed basis. The LPA toured a random selection of resident rooms in the assisted living and memory care unit and toured the common spaces and observed areas to be clean. During the visits conducted on 5/19/2023 and 5/31/2023, the LPA observed housekeeping staff actively cleaning resident rooms and facility common areas. Based on the information obtained, there is insufficient evidence to support the claim that the facility is unclean. This allegation is deemed Unsubstantiated at this time. Allegation: Staff failed to provide a comfortable environment for residents It is alleged that staff were overheard to be speaking inappropriately amongst each other in common spaces (resident hallways). Staff allegedly were laughing and talking about weekend plans, and not tending to resident care needs. Interviews with care staff supported claims that they do have casual conversations amongst each other. Interviews with residents denied claims that they have overheard staff having inappropriate conversations or felt uncomfortable. Information from staff interviews reveled that staff have casual check ins with each other but refrain from conversations being inappropriate in nature. During the visits conducted on 5/19/2023 and 5/31/2023, the LPA observed staff speaking amongst each other in facility common areas however did not observe any inappropriate conversations. Residents also denied concerns with staff's ability to respond to care needs timely. Based on the information obtained, there is insufficient evidence to support the claim that the Staff failed to provide a comfortable environment for residents.This allegation is deemed Unsubstantiated at this time. CONT 9099-C Page 3 Allegation: Staff failed to issue a refund It was alleged that staff failed to issue a refund. Interviews and records review confirmed that R1 was admitted on 3/4/2023, and subsequently moved out on 3/5/2023. Staff claimed that they had submitted a claim to corporate for a refund of the community fee but could not speak to the reason as to why it took a long time for R1’s responsible party to receive a refund. Records indicated that a check was issued to R1’s responsible party on 05/18/2023 in the amount of $500. Staff interviews confirmed that if an assessment had been completed by the care team, R1’s responsible party would have only received a refund in the amount of $500. Although R1’s responsible party claimed that they were unaware of the reason as to why they did not receive the full refund, records review confirmed that R1’s responsible party had signed a ‘Refundable Community Fee’ agreement on 02/17/2023, which indicated that the community fee of $1000 was to cover the costs associated with processing paperwork, completing an assessment, and resident orientation. The agreement also indicated that after an assessment is completed, the first $500 of the community fee becomes non-refundable. An interview with R1’s responsible party confirmed that they received a refund in the amount of $500. Staff provided the LPA with a copy of the appraisal dated 3/2/2023. In addition, although R1’s responsible party signed the Refundable Community Fee agreement, which states the terms of receiving a refund for the preadmission fees, it is alleged that the document was not explained in detail. Due to the conflicting information received from all parties involved during interviews and records review, there is insufficient evidence to support the allegation. The above allegation is Unsubstantiated at this time. No deficiencies cited at this time. Exit interview conducted. A copy of the report was issued.the state’s words, verbatim · CDSS document, May 31, 2023 · control 29-AS-20230427100226

The state marks this report as 4 pages; the online copy we transcribed has 3. You can request the full file from the county licensing office.

Allegation investigated: Staff did not administer resident’s medication as needed

Licensing Program Analyst (LPA) Angel Ascencio conducted a subsequent complaint visit to the above facility. LPA Ascencio met with Executive Director Elizabeth Whittington at 9:20 a.m. Entrance interview conducted. On 10/12/2022, the Department (RO) received a complaint alleging that there has been various occasion that staff did not administer resident’s medication as needed. On 01/23/2023, interview with R1 revealed there was only one (1) instance R1’s blood pressure medication was given late. R1 was out of the facility with family and upon R1’s return, their blood pressure was high. R1 requested medication from the medication technician (med tech) and initially refused to give R1 their blood pressure medication but after some time, the med tech gave R1 the medication. Otherwise, R1 stated there has not been any other medication incidents since December 2021. Continued on LIC 9099 - C Substantiated A file review for R1 was conducted on 03/01/2023, which revealed that R1 can do their own blood pressure and request for medication to self-administer medication. At the time of the file review, R1 has an as need (PRN) medication for blood pressure medication. Additionally, interviews with various residents on 02/22/2023, 03/01/2023, and 05/05/2023 revealed that they have not had any problems with medication, requesting medication or a lapse in medication. However, LPA Ascencio, LPA Ashley Morgan and LPA Elsie Campos conducted a medication audit on 05/19/2023, starting at 12:00 p.m. revealed that two (2) residents (which included an audit of R2’s medications) did not have their “as needed” medication at the facility specific for blood pressure. Due to this, if R1 requested additional blood pressure medication, the facility would not be able to assist R1 with their blood pressure medication. Thus, based on evidence gathered, the allegation of staff did not administer medication as needed is substantiated at this time. The following deficiencies were observed (See LIC 9909-D.) and cited from the California Code of Regulations, Title 22 and California Health and Safety Code. Failure to correct the deficiencies may result in civil penalties Exit interview conducted and a copy of the report and appeal rights were issued to ED. Additionally, ED Spitznogle stated that staff reported R1 having very frequent incontinence issues while being in bed. On 10/06/2022, R1 was sent out to be evaluated. On 10/16/2022, R1 returned to the facility with tubes in their back and a diagnosis of Acute Renal Failure. According to the Mayo Clinic, “Acute kidney failure — also called acute renal failure - occurs when your kidneys suddenly become unable to filter waste products from your blood.” ED Spitznogle added that R1 was sent out to the hospital on 10/23/2022 because R1 had pulled their tubes out of their body. R1 was admitted to the hospital, then transferred to a skilled nursing facility (SNF) and was re-admitted to Pacifica Senior Living on 12/02/2022. On 12/19/2022, R1 had an unwitnessed fall, was sent out to the hospital and did not return to the facility. Staff interviews on 10/12/2022, and 03/07/2023 confirmed what ED Spitznogle stated. Additionally, staff stated that R1 would request assistance from the care staff who would assist R1 in their incontinence needs. Lastly, staff indicated that staff would constantly give R1 water as staff were aware of R1’s diagnosis. Although R1 was considered independent, an apparent change in condition in R1 caused facility staff to be proactive and seek medical attention while addressing his needs due to his diagnosis. On 10/13/2022, 03/09/2023 and 05/02/2023, a file review on R1 was conducted confirming what ED Spitznogle and staff stated. Additionally, R1’s file review indicated that R1 moved into Pacifica Senior Living Oxnard on 02/12/2022, uses a wheelchair or walker to ambulate within the facility, required minimal assistance with transfers, dressing, bathing, grooming, and required no assistance with eating, toileting and managing cash resources. R1’s Physician’s Report indicated that R1 had a diagnosis of chronic kidney disease (stage 2) and seven (7) other conditions. According to the Mayo Clinic, your kidneys filter wastes and excess fluids from your blood, which are then removed in your urine. Advanced chronic kidney disease can cause dangerous levels of fluid, electrolytes and wastes to build up in your body. Further file review for R1 revealed four (4) Internal Incident Reports and Narrative Charting notes indicating R1’s incidents and staff seeking medical attention, confirming what ED Spitznogle and staff stated. Lastly, hospital discharge documents and hospital charting notes, dating 10/19/2022, confirmed R1’s primary diagnosis of chronic kidney disease as well as notes stating R1 “started on antibiotics due to a UTI, although test done did not indicate infection” and “unclear if active infection for UTI.” Even though R1 was independent, staff interviews indicated that R1 had a change in condition and depended on staff assistance with activities of daily living. The physicians report and hospital records confirmed that R1’s primary diagnosis as Acute Renal Failure while a hospital charting note indicated a possibility of a possible UTI but could not be confirmed. Continued on LIC 9099 - C The Department understand having a diagnosis of chronic kidney disease give a person a higher risk for frequent UTI. Although staff cannot prevent UTIs from happening, their knowledge of R1 diagnosis and being proactive with the circumstance, staff were able to find the necessary assistance R1 needed. Thus, the allegation of resident sustained a bladder infection and a urinary tract infection (UTI) while in care of facility is deemed unsubstantiated at this time. Regarding staff did not seek timely medical attention for resident. Interview with Executive Director (ED) Kortnie Spitznogle on 10/13/2022, starting at 1:16 p.m. and on 01/04/2023 starting at 12:25 pm, revealed that although R1 was considered independent, R1 required staff assistance with activities of daily living (ALD) from August 2022 through December 2022. ED Spitznogle added that R1 started presenting with unusual behaviors such as staying in bed, not wanting to eat, and having incontinence issues causing various incidents between August 2022 and October 2022. Additionally, ED Spitznogle stated that staff would report the incident to the ED, R1’s family members and R1’s doctor, but ultimately, it was R1’s decision to refuse care. The few times R1 went to the hospital, it was because R1’s family member convinced R1, or R1 was feeling very bad. On 10/06/2022, R1 was sent out to be evaluated and returned on 10/16/2022, with tubes in their back. ED Spitznogle added that R1 was sent out to the hospital on 10/23/2022 because R1 had pulled their tubes out of their body. R1 was admitted to the hospital, transferred to a skilled nursing facility (SNF) and was re-admitted to Pacifica Senior Living on 12/02/2022. Lastly, ED Spitznogle added that on 12/19/2022, R1 had an unwitnessed fall, initially refused medical services but was sent out to the hospital after speaking with R1 and R1’s family member. R1 did not return from recent hospitalization. Staff interviews on 10/12/2022, and 03/07/2023 confirmed what ED Spitznogle stated. Additionally, staff stated that R1 would request assistance from the care staff who would assist R1 in their needs. When staff would arrive at R1’s bedroom, there were a handful of incidents that R1 would not be feeling well and staff would call 911, but R1 would refuse to leave for additional medical attention. Additionally, staff interviews indicated they document any refusal from any resident that experiences incidents that require medical attention. Lastly, staff indicated that depending on the severity of incident, when staff recommends medical attention and resident refused, staff will contact the resident responsible party to convince to seek medical attention. Although R1 was considered independent, an apparent change in condition in R1 caused facility staff to be reactive and seek medical attention, while understanding R1’s right to refuse medical care. Continued on LIC 9099 - C On 10/13/2022, 03/07/2023 and 05/02/2023, a file review on R1 was conducted confirming what ED Spitznogle and staff stated. Additionally, R1’s file review indicated that R1 moved into Pacifica Senior Living Oxnard on 02/12/2022, and required minimal assistance with transfers, dressing, bathing, grooming, and required no assistance with eating, toileting and managing cash resources. Further file review for R1 revealed two (2) Internal Incident Reports, 09/21/2022, and 12/09/2022, and Narrative Charting notes, 09/21/22, indicating R1’s incidents, staff seeking medical attention for R1 and R1 refusing medical care, confirming what ED Spitznogle and staff stated. Although the staff did seek medical attention for R1 and documented those occurrences, R1 exercised his right to refuse medical care when emergency medical services arrived. The facility did its due diligence in calling emergency service when an incident happened, and, although R1 refused medical services, the facility was reactive in reaching out to R1’s family member for additional help and guidance, ultimately seeking treatment for R1. Thus, the allegation of staff did not seek timely medical attention for resident is deemed unsubstantiated at this time. Lastly, regarding staff did not properly prepare food in result of resident getting food poisoning. Interview with Executive Director (ED) Kortnie Spitznogle on 10/13/2022, starting at 1:16 p.m. and on 01/04/2023 starting at 12:25 pm, revealed that they have not heard on any resident having any food poisoning because of the food prepared here. ED Spitznogle stated that in April 2022, there was a norovirus outbreak that was reported to Community Care Licensing (CCL) and Ventura County Public Health (VCPH). We also had some type of stomach flu a few weeks ago but that was both staff and resident. Currently, we have 2-3 resident that are exhibiting loose bowel symptoms, but those residents are on special medication that causes these types of symptoms. ED Spitznogle stated that they were in the kitchen prepping and cooking food for the community, but most recently have hired a Dinning Service Director (DSD) as their main chef. Interview with three (3) staff on 03/07/2023, revealed that there was an incident over a year ago with the norovirus, but have not hear of any issues in recent times. Interviews with staff also revealed that residents complain of the food being served as being undercooked and not of good quality. Additionally, staff interviews indicated that 3 residents are the only resident with incontinence issues as two (2) residents take medication while the other has a medical issue. Lastly, staff interviews advised LPA to look in resident charting notes as staff record any incontinence problems any residents have. Continued on LIC 9099 - C Residents file review was conducted on 10/13/2022, 03/07/2023 and 05/02/2023, revealing that R2 had an incontinence episode on 08/09/2022, R3 had incontinence episode on 08/09/20233 and 08/14/2022, and R4 had and incontinence episode on 08/01/2022. LPA Ascencio did not find any other supporting documents relating to incontinence episode for other residents. On 05/02/2023 and on 05/05/2023, interview with seven (7) residents revealed that they have not experience any food poisoning or have not heard of any resident having food poisoning because of the food at the facility. Lastly, residents had mix feeling about the food being serve with some resident enjoying the food and other not liking it. Even though there was a substantiated complaint on 10/25/2022 that addressed poor quality of food, staff and resident interviews indicated that there was a Norovirus outbreak in April 2022 that was reported but no evidence of food poisoning at this time. In addition, resident charting notes revealed only 3 residents having incontinence problems, but those incidents were attributed to medical or medication issues. Thus, based on evidence gathered this allegation is unsubstantiated at this time. Exit interview conducted and copy of the report was issued to the Administrator.the state’s words, verbatim · CDSS document, May 19, 2023 · control 29-AS-20221012131509

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(4) · Plan of correction due date: May 22, 2023

87465 Incidental Medical and Dental Care (a)(4)A plan for incidental medical and dental care shall be developed by each facility... The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by: Based on a medication audit, the licensee did not comply with the section cited above as R1 and R2 did not have their PRN blood pressure medication at the facility which staff cannot assist residents with self-adminsitration of medication which poses an immidiate health and safetey risk to resident in care.the state’s words, verbatim · CDSS document, May 19, 2023

Plan of correction: Administrator will conduct Med Audit for all PRN meds in 2 days. Administrator will submit a plan on how to obtain PRN medication for R1 and R2 and submit by 05/22/2023.

Allegation investigated: Resident experiencing numerous falls and injury(ries) at facility due to lack of supervision.

Licensing Program Analyst (LPA) Angel Ascencio conducted a subsequent complaint visit to the above facility. LPA Ascencio met with Executive Director(ED) Elizabeth Whittington at 12:10 p.m. Entrance interview conducted. On 10/12/2022, the Department (RO) received a complaint regarding resident experiencing numerous falls and injury(ries) at facility due to lack of supervision. Interview with Executive Director (ED) Kortnie Spitznogle on 10/13/2022, starting at 1:16 p.m. revealed that Resident #1 (R1) moved into the facility on October 3th, 2022 after being discharged from a skilled nursing facility. The following day, R1 had a fall and went to the hospital and did not return. ED Spitznogle stated that during resident assessment, there was no concern for R1, but was very unhappy, depressed, and withdrawn. Continued on LIC 9099 - C Substantiated Interview with Staff #1 (S1) on 03/07/2023 at 10:47 a.m., and 03/09/2023 at 12:45 p.m. confirmed R1’s singular fall and mental state. Additional staff interviews on 10/12/2022, and 03/07/2023 revealed that R1 had three (3) falls on 10/04/2022. Staff stated only two (2) staff members were working that day and they helped assist R1 to their bed after two falls. After assisting R1, staff indicated they verbally let the medication technician know what happened. Further staff interviews revealed that on R1’ s 3rd fall, 911 was contacted, and R1 was sent out to the hospital and was admitted that same day. Staff interviews also confirmed R1 did not come back to Pacifica after being hospitalized. Staff interviews also indicated that when a resident has a fall, the medication technician is notified, assess the resident and notifies the Executive Director and management of the fall. Lastly, staff indicated that they are unsure if the two (2) falls were reported to management but, on the 3rd fall, R1 was sent out to hospital. Although ED Spitznogle and staff stated only one (1) fall was recorded and reported, additional staff interviews confirmed that on 10/04/2022, multiple staff observed R1, on 3 separate occasions, on the floor from a fall. LPA Ascencio reviewed the Incident Report for R1 dated 10/04/2022, which indicated 1 fall occurred. Additionally, a narrative charting entry and a physician commutation form was observed, both indicating that R1 had one (1) fall on 10/04/2022. Review of R1’s medical records on 03/01/2023, revealed R1’s diagnosis of sepsis, difficulty walking, muscle weakness, age-related physical disabilities, and ten (10) other medical diagnoses, according to the Physicians Report. Additionally, the Physician’s Report also indicates R1 was able to bathe, dress/groom, feed self and able to care for own toileting needs with minimal assistance. Lastly, R1’s facility assessment indicates bathing, dressing, transfer, toileting and escort require total assist from Pacifica staff. Even though, R1’s physician report indicated minimal assist with activities of daily living (ADL), Pacifica’s plan of care indicates R1 depends on staff assistance for all ADLs. R1’s discharged document, dated 09/27/2022, from a skilled nursing facility (SNF) indicated that R1 had multiple falls and was considered a fall risk. Therefore, due to R1’s facility assessment indicating total assistance with ADLs, knowledge of R1 being a fall risk from documentation, and multiple staff admitting that R1 had three (3) falls on 10/04/2022, R1 sustained multiple falls at the facility based on lack of care and supervision. Based on evidence gathered, there is sufficient evidence to support the allegation of resident experiencing numerous falls and injury(ries) at facility due to lack of supervision. Thus, the allegation is substantiated at this time. Continued on LIC 9099 - C A similar complaint was substantiated on 05/24/2022. An immediate civil penalty of $1,000.00 was assessed on 05/02/2023 due to repeat violation. 1 citation was issued. Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 9099-D). Exit interview conducted and copy of the report and appeal rights were issued to ED.the state’s words, verbatim · CDSS document, May 2, 2023 · control 29-AS-20221012131509

From the deficiency page — Deficiency type: Type A · Section cited: HSC 1569.312(a) · Plan of correction due date: May 3, 2023

1569.312(a) Basic service requirements. Every facility required to be licensed under this chapter shall provide at least the following basic services: (a) Care and supervision as defined in Section 1569.2 This requirement is not met as evidenced by: Based on interviews and records review, the licensee did not comply with the section cited above as the licensee did not provide adequate care and supervision or seek higher level of care to R1 which attributed to R1 sustaining multiple falls within 1 day which poses an immediate health, safety and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, May 2, 2023

Plan of correction: Administrator stated they will conduct training on care and supervision to provide basics services. Administrator will provide copies to LPA via email by 5/12/23.

The state marks this report as 5 pages; the online copy we transcribed has 4. You can request the full file from the county licensing office.

Type of visit: Case Management - Other

On April 28, 2023, Licensing Program Analyst (LPA) KaSandra Lopez met with Administrator Elizabeth Whittington for a Case Management visit to issue a civil penalty per Health & Safety (H&S) Code §1569.49(f). On September 2, 2020, the Department received a complaint alleging, “Resident #1 (R1) sustained multiple pressure injuries while in care,” and, “Facility staff did not seek medical attention for Resident #1 (R1).” It was alleged due to facility staff neglect and lack of supervision, R1 sustained multiple pressure injuries, and that facility staff failed to seek timely medical attention for R1. To investigate, the Department conducted visits to this facility on September 2, 2020, December 17, 2020, November 4, 2021, March 15, 2022, and March 18, 2022. Interviews were conducted with R1’s family, R1’s hospice agency staff and facility staff. R1’s facility and hospice records were also obtained and reviewed. The investigation revealed R1 was admitted to this facility on June 1, 2020. R1 was ambulatory and able to articulate their needs, despite having suffered a prior stroke and showing signs and symptoms of dementia. R1’s medical history included depression, frequent urinary tract infections, heart disease, stroke, and dysphagia. The licensee’s narrative charting record for R1 indicated on July 25, 2020, R1 was found by a caregiver sitting on the floor in the middle of their living room. R1 was noted as becoming weaker and in need of total assistance with toileting and feeding. On August 2, 2020, R1’s physician was contacted to obtain authorization for medical assistance as R1 “seemed a lot weaker,” and appeared in need of “a lot” more assistance. On August 15, 2020, R1’s representative visited R1 in this facility and bandaged R1’s legs due to R1’s itching and scratching, which caused bleeding. Band-aids were also placed on R1’s arms; however, R1 took them off twice, and R1’s representative was notified. Prior to August 15,2020, facility staff did not inform R1’s representative that R1 had not been ambulating on their own over a few weeks. Report continued on LIC 809-C. On August 20, 2020, R1 was assessed and admitted to TLC Hospice Care due to Alzheimer’s disease and a rapid decline in health. During the hospice assessment, R1 was observed to have a large stage 1 area on the coccyx with multiple scabs, and stage 2 areas within; a large skin tear to R1’s left lower leg; and, multiple open sores to both forearms. The assessment also noted since admission to this facility, R1 had rapidly declined, required support with all activities of daily living, and was in severe discomfort and significant pain. Information gathered further revealed it was not until hospice care initiated on August 20, 2020, that R1’s pressure injuries and wounds were diagnosed, treated and reported to R1’s representative. On August 22, 2020, the hospice nurse indicated R1 had moderate pain of a “6” in a Pain Scale as follows: [pain scale is to provide a standardized means of measuring pain intensity and severity, Pain Free 0, Mild Pain = 1-3, Moderate pain = 4-6, Severe Pain = 7-10…disabling or unable to carry out normal daily activity - https://connect.mayoclinic.org/]…” On August, 24, 2020, the hospice nurse noted R1 was in severe pain, which was rated as a “9,” requiring pain medication (morphine). The licensee’s Residential Care Director (RCD) stated they were never made aware of R1’s pressure injury nor scattered skin tears, until R1 was accepted into hospice care. The RCD admitted the facility staff’s lack of documentation and communication, but also failing to provide appropriate supervision and care, attributed to neglecting R1’s change of condition and pressure injury/wound care needs going unmet. A review documentation obtained also reflects R1 did not receive the care and supervision necessary to address R1’s nutritional status (weight loss of 20 pounds in two months). Based on the records reviewed, interviews conducted, and photographic evidence of R1’s wounds/pressure injuries, facility staff neglect/lack of supervision and care was determined to have attributed to R1 sustaining pressure injuries. On March 18, 2022, licensing staff substantiated allegations, “Resident #1 (R1) sustained multiple pressure injuries while in care,” and, “Facility staff did not seek medical attention for Resident #1 (R1).” The licensee was cited for violating Health and Safety Code §1569.312, Basic Services Requirements, and for violating California Code of Regulations (CCR) Title 22, Section 87466 Observation of the Resident. On March 18, 2022, an immediate civil penalty of $500 was assessed and the licensee was informed that an additional civil penalty might be assessed based on Health and Safety Code §1569.49. Report continued on LIC809-C. The Department has concluded an analysis and has determined that a civil penalty is warranted for a violation that resulted in R1 sustaining serious bodily injury while under the care of this facility. Welfare and Institutions Code §15610.67 defines serious bodily injury as “an injury involving extreme physical pain, substantial risk of death, or protracted loss or impairment of a function of a bodily member, organ, or of mental faculty, or requiring medical intervention, including but not limited to, hospitalization, surgery, or physical rehabilitation.” This is evidenced by the licensee’s failure to properly evaluate and provide R1 with appropriate care and medical treatment. Based on the documentation reviewed, R1 did not receive the care and supervision necessary to address R1’s nutritional status (weight loss of 20 pounds in two months), and prevent or minimize the risk for skin integrity issues, causing R1 to develop wounds and a stage 2 pressure injury, contributing to R1’s severe pain (9/10). These deficiencies were a substantial factor in causing R1’s extreme pain/serious bodily injury, as indicated by the hospice nurse. Today, April 28, 2023, the Department is issuing a civil penalty per Health and Safety Code §1569.49(f) in the amount of $10,000 for a violation that the Department constitutes as serious bodily injury. However, since an immediate civil penalty of $500 was previously issued on March 18, 2022, the amount of the civil penalty issued is reduced to $9,500. A copy of the LIC 421D was given to the Elizabeth Whittington and originals were signed. Exit interview conducted. A copy of the report issued. Appeal Rights provided. Elizabeth Whittngton signature on this report acknowledges receipt of the Appeal Rights, found on page two of LIC 421D.the state’s words, verbatim · CDSS document, Apr 28, 2023

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Teresa Camara conducted a case management - incident visit regarding an incident which took place on 4/10/2023 in which resident 1 (R1) left the facility without being accompanied by staff. R1 was later found by police at approximately 2:00 p.m., confused and lost. The police brought R1 back to the facility the same day. LPA met with administrator/executive director Elizabeth Whittington at 10:25 a.m. LPA reviewed and obtained pertinent records at 12:40 p.m. LPA interviewed staff 1 (S1) at 12:30 p.m. LPA's review of records showed the facility has a physician's report on file for R1 which states R1 cannot leave the facility unassisted. S1 stated the facility receptionist has a list of residents who are not allowed to leave the facility unassisted. The facility has a "Resident Sign Out/In Log" and it is their policy for all residents to use this log when they leave the facility and return. When a resident is signing out the receptionist is to confirm the resident is allowed to leave the facility without assistance from staff. LPA Camara reviewed the "Resident Sign Out/In Log" for 04/08/2023 - 04/15/2023 and observed R1 signed out on 4/8/2023 at 2:13 p.m., 4/9/2023 1:37 p.m. and 4/10/2023 at 1:02 p.m. Each time stating they were going to Walmart. Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D). Exit interview conducted. Appeal Rights Discussed. A copy of the report was provided.the state’s words, verbatim · CDSS document, Apr 21, 2023

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87464(d) · Plan of correction due date: Apr 28, 2023

87464 Basic Services (d) A facility need not accept a particular resident for care. However, if a facility chooses to accept a particular resident for care, the facility shall be responsible for meeting the resident's needs as identified in the pre-admission appraisal specified in Section 87457, Pre-admission Appraisal and providing the other basic services specified below, either directly or through outside resources. This requirement is not met as evidenced by: Based on interviews and record review, the licensee did not comply with the section cited above, as staff were aware R1 was not to leave the facility unassisted but failed to ensure R1 had assistance when theythe state’s words, verbatim · CDSS document, Apr 21, 2023

Plan of correction: Administrator will immediately ensure staff do not allow residents who need assistance to leave the facility without such assistance. In addition, administrator will provide evidence of training caregivers and receptionists regarding these policies to CCL on or before 4/28/2023. signed out to leave the facility on 4/8,9&10/2023, which poses an immediate health and safety risk to persons in care.

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Teresa Camara conducted a case management - deficiencies visit due to a deficiency observed during the course of a complaint investigation of complaint control number 29-AS-20230418134450. LPA conducted interviews regarding the above noted complaint with resident 1 (R1) at 1:15 p.m., staff 1 (S1) at 1:50 p.m. and staff 2 (S2) at 1:55 p.m. During the interviews it was found that an incident took place on or about 3/31/2023 in which cash and a debit card were stolen from R1's purse which was kept inside R1's closet. Unauthorized transactions were discovered to have been made with the stolen debit card. S2 stated it was their understanding R1's family reported this to the facility's community relations director and/or the facility's Resident Care Director, both of whom are working on conducting further investigation into the allegation. The report from the family to facility staff was received on or around the first week of April 2023. LPA reviewed incident reports received by the Department from the facility, however no incident report was received regarding this incident. An SOC341 was received by the Department, however that was not filed by the facility. Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D). Exit interview conducted. Appeal Rights Discussed. A copy of the report was provided. Civil penalty assessed.the state’s words, verbatim · CDSS document, Apr 21, 2023

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1)(D) · Plan of correction due date: Apr 28, 2023

87211 Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case. (D) Any incident which threatens the welfare, safety or health of any resident, such as psychological abuse of a resident by staff or other residents, or unexplained absence of any resident.the state’s words, verbatim · CDSS document, Apr 21, 2023

Plan of correction: Administrator will submit an incident report regarding the allegation of theft and provide evidence of training staff on reporting requirements. This will be provided to CCL on or before 4/28/2023. This is a repeat violation; civil penalty assessed in the amount of $250. This requirement is not met as evidenced by: Based on interviews, the licensee did not comply with the section cited above, as staff were aware of an inciduent of stolen valuables but did not report it to the Department, which poses a potential health and safety risk to persons in care.

Allegation investigated: Resident’s room has mold.

Licensing Program Analyst (LPA) Angel Ascencio conducted a subsequent complaint visit to the above facility. LPA Ascencio met with Interim Executive Director (ED) Jade Alma at 11:28 a.m. Entrance interview conducted. On 10/12/2022, the Department (RO) received a complaint regarding resident’s room had mold. Interview with Executive Director (ED) Kortnie Spitznogle on 10/13/2022, starting at 1:16 p.m. revealed that staff reported to ED Spitznogle regarding possible mold in Resident #1’s (R1) room. ED Spitznogle stated the ED and an Interim Maintenance Director looked at R1’s room and could not identify the type of stains in R1’s apartment wall. ED Spitznogle purchased cleaning solution and paint to fix the issue. Additionally, ED Spitznogle added that there was a room upstairs that they found was leaking water, which was fixed. Later that same day, interview with R1, starting at 4:10 p.m. confirmed what ED Spitznogle stated and, according to R1, believed it was mold on the wall but was unsure. Continued on LIC 9099 - C Unsubstantiated LPA Ascencio observed R1’s private apartment on 10/12/2022, 10/25/2022, and 02/22/2023 which revealed that the south side apartment wall has visible water stains marking's that have been painted over. Additionally, on 02/22/2023, LPA Ascencio, LPA Ashley Morgan and LPA Esther Cortez walked into a housekeeping closet adjacent to R1’s apartment, and three (3) residents’ room above R1’s apartment and did not observe any water leaks or mold that could have affected R1’s apartment walls. Although interviews with R1 and ED Spitznogle stated they were unsure the stains in R1’s apartment wall was mold, it was revealed that the walls were cleaned, treated and painted for preventative measures but, the south wall has visible stain marking's that are unknown whether they are mold or water damage. On 02/22/2023 and on 03/09/2023, in the common area, next to the dinning room, there is a large, discolored corner area that looks like water damage. LPA Ascencio spoke with the Interim ED regarding R1’s visible stains and possible water damage in the common area. Interim ED stated the currently don’t have a Maintenance Director but will hire and a professional to look at R1’s room and the water damage in the common area. Based on the information obtained, there is insufficient evidence to support the claim that resident’s room has mold. Thus, the allegation above is deemed Unsubstantiated at this time. Exit interview conducted and copy of the report was issued to business Office Manager and Interim ED.the state’s words, verbatim · CDSS document, Mar 9, 2023 · control 29-AS-20221012131509

The state marks this report as 3 pages; the online copy we transcribed has 2. You can request the full file from the county licensing office.

Allegation investigated: Resident's oral hygiene needs were not met Resident did not receive medical care in a timely manner

Licensing Program Analyst (LPA) Angel Ascencio conducted a subsequent visit to deliver findings to the above facility. LPA Ascencio met with Business Office Manager (BOM) Cynthia Garcia at 8:55 a.m. Entrance interview conducted. On 01/13/2022, the Department received a complaint alleging that resident’s oral hygiene were not met and resident did not receive medical care in a timely manner. On 01/20/2022, starting at 10:18 a.m., LPA Kelly Dulek conducted an interview with Executive Director (ED) Kortnie Spitznogle. Interview with ED Spitznogle revealed that Resident #1 (R1) has been on hospice for Alzheimer’s Disease since October 2021. Due to R1’s diagnosis, R1 would try to bite staff when staff attempted oral hygiene or when staff are feeding R1. Because of this behavior, R1 developed oral thrush. The hospice nurse became aware of the thrush and requested staff to continue with oral hygiene care for R1. ED Spitznogle lastly added that the staff attempted various times to provide oral care but were never successful due to R1’s behaviors. Continued on LIC 9099 - C Unsubstantiated On 03/01/2023, LPA Ascencio reviewed R1’s medical records which confirmed R1’s diagnosis and admission to hospice. Additionally, various narrative charting notes revealed that on 01/09/2022, “Resident spit out ensure this AM. Cleaned resident mouth and lips.”, and on 01/10/2022, “ Nurse from Los Robles Hospice came for a visit. Nurse stated residents’ mouth was very dry and had chocolate ensure. Resident has been combative not allowing mouth care. Nurse will call family member and ask for mineral oil for dryness.” Later that same day, review of hospice documentation revealed that on 01/05/2022 oral care was discussed with Pacifica staff. On 01/10/2022, “Pt mouth was dry & crackling. PT won’t allow for mouth care, tries to push away” and oral mineral oil was recommended. On 01/12/2022, oral care was provided by hospice nurse. On 01/14/2022, R1’s hospice physician wrote an order to provide oral care 3x a day. R1 passed away on 01/18/2022. Prior to 01/05/2022, there was no written documentation regarding the need for oral care in either Pacifica Senior Living documentation or Hospice Documentation. Although staff documentation stated they attempted to do their due diligence in conducting oral hygiene for R1 after 01/05/2022, documentation from hospice agency confirmed the attempts and behavior episodes of R1. LPA Ascencio attempted various times to conduct interview with Hospice Agency worker but was unsuccessful. Interview with two (2) staff members on 03/7/2023, starting at 11:09 a.m., confirmed R1’s aggressive behaviors towards staff and other residents. Additionally, staff members added that R1 would not allow staff to help R1 with any activities of daily living, thus R1’s health would rapidly decline. Although facility and hospice documentation stated staff attempted and provided minimal oral care for R1, there was no documentation regarding an infection or disease in R1’s mouth. Additionally, the Department received the complaint on 01/13/2022, alleging of resident's oral hygiene needs were not met, but on 01/14/2022, hospice physician wrote an order to provide oral care. Staff interviews could not validated whether oral care was provided after the written order of 01/14/2022, but the ongoing struggle of R1’s aggressive behavior to provide oral care or any ADLs was documented both by Pacifica and Hospice. Based on the information obtained, there is insufficient evidence to support the claim that the resident’s oral hygiene was not met. Thus, the allegation above is deemed Unsubstantiated at this time. Continued on LIC 9099 - C Regarding the allegation of resident did not receive medical care in a timely manner. R1 was admitted to hospice care on 10/11/2021 with a terminal diagnosis of Alzheimer’s Disease. According to hospice documentation reviewed on 03/01/2023, it was revealed that R1 was being visited by hospice agency representatives 3-5 times each week for the months of November and December 2021. Because R1 was on hospice, R1 was seen frequently by a nurse, health aide, medical social worker and chaplain. Review of Pacifica’s documentation on 03/01/2023, revealed that due to R1’s advance stage of Alzheimer’s Disease, there were very frequent falls and aggressive behaviors towards staff and other residents. Documentation also revealed staff communicating with R1’s family member and hospice agency when any behaviors and fall occurred. Hospice documentation revealed that on 01/05/2022 oral care was discussed with Pacifica staff, yet hospice representatives also knew and documented about R1’s behaviors and the refusal of care. Additionally, hospice intake documentation state “Do not call 911. Call us first.” Per a review of notes and staff interviews, there was no indication that R1 required immediate medical care outside of the conversation with the hospice nurse regarding R1’s oral care on 01/05/2022. Prior to the 01/05/2022 conversation, facility notes nor hospice notes prior to this date indicated any concerns regarding R1. As previously stated, parties were aware of R1’s refusal of care and behavioral challenges. After the conversation with the hospice nurse, staff documented efforts in tending to R1’s hygiene and oral needs. Although the complaint alleging resident did not received medical care in a timely manner was submitted to the Department on 01/13/2022, R1 was being seen by the hospice agency since date of admission on 10/11/2021 until death in 01/18/2022. Based on the information obtained in interviews and record review, there is insufficient evidence to support the claim that the resident did not receive medical care in a timely manner. Thus, the allegation above is unsubstantiated at this time. Exit interview conducted and a copy of the report was issued to BOM.the state’s words, verbatim · CDSS document, Mar 7, 2023 · control 29-AS-20220113102423

Allegation investigated: Staff are not providing adequate food service to resident's

Licensing Program Analyst (LPA) Angel Ascencio conducted a subsequent visit to deliver the findings to the above facility. LPA met with Business Office Manager (BOM) Cynthia Garcia at 9:15 a.m. Entrance interview conducted. On 12/27/2021, the Department (RO) received a complaint regarding staff are not providing adequate food service to residents. Interview with Resident #1 (R1) on 01/03/2022, starting at 1:23 p.m. , on 10/13/2022, starting at 1:20 p.m. and on 01/04/2023, starting at 12:10 p.m., revealed that there have been various times that food was not delivered on time. R1 stated that on 12/25/2021, no staff came to escort R1 to the dining room for dinner. Additionally, R1 stated there have been times that they eat in their rooms only to have the dining room staff forget an essential item like coffee, butter, and silverware. Lastly, R1 added that on 01/22/2023, R1 and all the residents at the facility received their breakfast one (1) hour after the allotted time of 8:00 – 9:30 a.m. Continued on LIC 9099 - C Substantiated Two (2) resident interviews on 01/24/2023 with LPA Ashley Morgan confirmed what R1 had stated regarding breakfast arriving late on 01/22/2023. Interviews with eleven (11) residents on 10/13/2022, 01/04/2023, 01/23/2023, and 02/22/2023 revealed that although the facility does provide meals, the food being served is not of best quantity and quality. Additionally, staff often forgets utensils and condiments that go with the meal, thus, delaying residents’ food. Additionally, when the food is delivered to the resident’s room, most of the time, the meals arrive late and cold. Although interviews with resident stated that the food service was decent on some days, the majority of resident interviews stated they are unhappy with food services as their food often arrives late, cold, has missing items or utensils and may not be edible at times. Based on interviews and observation, the allegation of staff is not providing adequate food service to residents is deemed substantiated at this time. A similar complaint was substantiated on 02/22/23. 1 citation was issued. Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 9099-D). Exit interview conducted and a copy of the report and appeal right were issued to BOM. That same day, interview with the Resident Care Coordinator (RCC), starting at 12:43 p.m. revealed the medication training and process for all medication technicians at the facility. Additionally, the RCC added that a staff member approached them regarding R1’s PRN medication on 12/15/2021. RCC stated that after a while, the staff left the RCC’s office to give medication to R1. Interview with R1’s family member on 01/06/2022, starting at 3:07 p.m. confirmed what R1 stated as R1’s family member was present during the situation. Review of R1’s medical file on 03/01/2023 revealed that a clarification form was sent and signed on 06/18/2019, from Pacifica Senior Living Oxnard to R1’s Medical Doctor (MD) regarding the approval of the self-administration of medication, in addition, for R1 to take their own blood pressure and to inform staff if any medication is needed. A review of R1’s Medication Administration Record (MAR) revealed two (2) daily routine high blood pressure medications were self-administered on 12/15/2021, as well as a resident request PRN high blood pressure medication was self-administered that same day, at 4:43 p.m. Interviews with five (5) residents 02/22/2023 and 03/01/2023, revealed that residents have not had any problems with requesting additional medication if needed, they have not been refused medication and staff are tentative with their medication needs. Although R1 stated the staff member refused to give R1 additional blood pressure medication, R1’s MAR indicated that R1 received their daily routine blood pressure medication in a timely manner. Additionally, the MAR revealed that one (1) as needed blood pressure medication was requested and self-administer the same day based on MD orders. Based on interviews and record review, the allegation of staff did not assist with the self-administration of medication in a timely manner is deemed unsubstantiated at this time. A similar complaint was Unsubstantiated on 09/23/2022. Regarding staff did not help with the self-administration of resident's medication. Interview with Resident #1 (R1) on 01/03/2022, starting at 1:20 p.m. , revealed that R1 takes their own blood pressure daily based on MD orders. On 12/15/2021, blood pressure was higher than normal and requested additional medication. R1 stated they spoke to a staff member who refused to give R1 medication. R1 added that they eventually received help with the self-administration of medication. Review of R1’s MAR for the month of December 2021, revealed that R1 did received assistance with the self-administration of medication as prescribed by their MD. Additionally, R1 received help with the self-administration of 6 PRN medications for December 2021. Continued on LIC 9099 - C Interview with five (5) residents 02/22/2023 and 03/01/2023, revealed that some residents self-manage their own medication, while other resident obtain help with the self-administration of medication at the facility on a daily basis. Although R1 stated the staff member refused to give R1 additional blood pressure medication, R1’s MAR indicated that R1 received help with the self-administration of medication for the entire month of December 2021 based on MD orders. Based on interviews and record review, the allegation of staff did not help with the self-administration of medication is deemed unsubstantiated at this time. Exit interview conducted and copy of the report was issued to the BOM.the state’s words, verbatim · CDSS document, Mar 1, 2023 · control 29-AS-20211227152245

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.2(a)(4) · Plan of correction due date: Mar 17, 2023

87468.2 Additional Personal Rights of Residents in Privately Operated Facilities. (a)(4) Residents … shall have ... the following ... rights: To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency ...This requirement is not met as evidenced by: Based on interviews and evidence gathered throughout the investigation, the licensee did not comply with the section cited above as various residents stated that food service is inadequate which poses a potential health, safety and personal rights risk to residents on care.the state’s words, verbatim · CDSS document, Mar 1, 2023

Plan of correction: BOM stated they will create a plan for food services that maintains compliance with regulations and personal rights. BOM will deliver plan to LPA by 3/17/23.

Allegation investigated: Staff did not respond to resident's call button in a timely manner

Licensing Program Analyst (LPA) Angel Ascencio conducted a subsequent visit to deliver the findings to the above facility. LPA met with Business Office Manager (BOM) Cynthia Garcia at 9:15 a.m. Entrance interview conducted. On 12/10/2021, the Department (RO) received a complaint regarding staff did not respond to residents call button in a timely manner. On 03/01/2023, interviews with four (4) staff members, starting at 12:35 p.m. revealed that all residents in assisted living (AL) have a call button. When residents need assistance, they push the button alerting staff member on their pagers. Once a call button is pressed, staff head to the room as soon as possible or call for help, shut off the alert button with their own button they have, then assist the resident in need. Further interviews revealed that staff need to try to assist residents by the 4th call on their pager, which is about 15 minutes, but there have been times that they are not able due to lack of staff. Continued on LIC 9099 - C Substantiated Although staff stated they respond to the resident call buttons as soon as possible, staff believe the lack of equipment, such as pagers and walkies, contributes to the delayed response time when a resident calls for assistance. LPA reviewed the facility's procedures and policy at it pertains to call response and it states at the bottom in handwritten black ink, “Note: 15 min response time. Do not forget to reset!! Time is crucial!!”. LPA could not find anything else regarding response time. On 03/01/2023, starting at 12:00 p.m., LPA Ascencio reviewed the SMARTcare Alert Call Button report for Resident #1 (R1) which revealed that from 12/01/2021 - 12/13/2021 there were fifty-five (55) alert button announcements that have elapsed the company’s fifteen (15) minute policy. Additionally, further review of the SMARTcare report also revealed that there were fifteen (15) alerts that were never responded to from 12/01/2021 – 12/13/2021. Based on the information from the investigation, there is sufficient evidence to support the claim that staff are not responding to residents’ calls for assistance in a timely manner. This allegation is substantiated. Similar complaints were substantiated on 10/26/2021, 03/18/2022, 10/25/2022 and 02/15/2023. 1 citation was issued. Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 9099-D). Exit interview conducted and a copy of the report, and appeal rights were provided to BOM.the state’s words, verbatim · CDSS document, Mar 1, 2023 · control 29-AS-20211210101025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(2) · Plan of correction due date: Mar 17, 2023

87468.1 Personal Rights of Residents in All Facilities (a)(2) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement is not met as evidenced by: Based on record review and interviews, the licensee did not comply with the section cited above the staff did not respond to R1’s calls for assistance in a timely manner and R1's diapering needs were not met, which poses a potential health, safety and personal risk to persons in care.the state’s words, verbatim · CDSS document, Mar 1, 2023

Plan of correction: The VP of Operations agreed to the following: 1. Review policies and procedures around responding to pendants and addressing diapering needs to all staff. Send sign-in sheet to CCL no later than 3/17/2023. Obtained additonal equiptment for staff such as walkies, and pagers.

The state marks this report as 4 pages; the online copy we transcribed has 3. You can request the full file from the county licensing office.

Allegation investigated: Facilities food service is inadequate

This report was originally issued on 01/31/2023. The report was amened to change the finding based on additional information gathered on 02/22/2023. Licensing Program Analyst (LPA) Angel Ascencio, Ashley Morgan and Esther Cortez conducted a subsequent complaint visit to deliver findings to the above facility. LPA's met with Executive Director (ED) Kortnie Spitznogle at 9:30 a.m. Entrance interview conducted. The Woodland Hills North Regional Office (RO) received a complaint on 04/25/2022 regarding facilities food service is inadequate. On 04/25/2022, at 12:33 p.m. and around 4:37 p.m., LPA observed dining room staff with trays of food delivering to various residents within the facility. That same day, starting at 1:48 p.m., interview with Resident #1 (R1) revealed that the food arrived on time and was not cold. R1 added that there are days that the food arrives cold, other days, the food comes back warm, never hot. On 01/23/2023, starting at 12:30 p.m., interview with six (6) residents confirmed that the food temperature and delivery of food various daily. Continued on LIC - 9099 – C Substantiated Further interviews with residents also revealed the process of delivery of meals to rooms. Most of the time, the dinning room staff begin delivery of food at 8:00 a.m., starting with the 1st floor. Because they are delivering to 30 + residents, by the time dining staff reach the 3rd floor, the food is cold and arrives late. Other occasions, the dinning staff begin with the 3rd floor and work their way down to the 1st floor. Temperature and delivery times vary daily with it starting at 8:00 a.m.- 9:30 a.m. for breakfast, 12:00 p.m. - 1:00 p.m. for lunch and 5:00 p.m. - 6:00 p.m. for dinner. Interviews with staff six (6) staff members on 10/13/2022, 01/04/2023, and 01/23/2023 revealed that some staff claim they do their due diligence in ensuring that the residents get their meals on time. Staff interviews also indicated that due to an inadequate supply of perishable and nonperishable foods, meals are delayed on different days. Interview with R2 on 10/13/2022, starting at 1:20 p.m., on 01/03/2022, starting at 1:23 p.m. and on 01/23/2023, starting at 12:10 p.m., revealed that there have been various times that food was not delivered on time. R2 added that on 01/22/2023, R2 and all the residents at the facility received their breakfast one (1) hour after the allotted time of 8:00 – 9:30 a.m. Two (2) resident interviews on 01/24/2023 with LPA Ashley Morgan confirmed what R2 had stated regarding breakfast arriving late. During LPA Morgan's visit, LPA observed food being delivered late at 1:30 p.m. to a resident room. Interviews with eight (8) residents on 10/13/2022, 01/04/2023, 01/23/2023, 02/22/2023 revealed that although the facility does provide meals, the food being served is not of best quality, and the staff often forgets utensils and condiments. Additionally, when the food is delivered to the resident’s room, most of the time, the meals arrive late and cold. Although residents had mixed feeling about the temperature and delivery of food, staff also stated they try to do their due diligence in ensuring food service is adequate. Based on information obtained in interviews, there is sufficient evidence to support the claim that the facility food service is inadequate. A similar complaint was substantiated on 2/22/2023.the state’s words, verbatim · CDSS document, Feb 22, 2023 · control 29-AS-20220425095729

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.2(a)(4) · Plan of correction due date: Feb 27, 2023

87468.2 Additional Personal Rights of Residents in Privately Operated Facilities. (a)(4) Residents … shall have ... the following ... rights: To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency ... Based on interviews and evidence gathered throughout the investigation, the licensee did not comply with the section cited above as various residents stated that food service is inadequate which poses an potential health, safety and personal rights risk to residents on care.the state’s words, verbatim · CDSS document, Feb 22, 2023

Plan of correction: BOM stated they will create a plan for food services that maintains compliance with regualtions and personal rights. BOM will deliver plan to LPA by 2/27/23.

Allegation investigated: Staff did not ensure residents received meals in a timely manner

Licensing Program Analysts (LPAs) Ashley Smith, Angel Ascencio, and Esther Cortez arrived unannounced to conduct a subsequent visit. The LPA met with Executive Director Kortnie Spitznogle and explained the reason for the visit. However, the findings were delivered to Cynthia Garcia, Business Office Manager. On 01/24/2023, the LPA gathered documents, interviewed staff at 11:31 a.m., 11:55 a.m., 12:25 p.m., 12:43 p.m., 12:51 p.m., 1:36 p.m., 2:00 p.m., 2:40 p.m., and 3:33 p.m., and interviewed residents at 1:00 p.m., 1:25 p.m., 2:20 p.m., and 3:30 p.m. Additional staff interviews took place on 1/26/2023 at 4:35 p.m., and on 02/10/2023 at 2:14 p.m. Additional resident interviews took place on 02/10/2023 at 1:01 p.m. and 02/16/2023 at 10:35 a.m. An interview was conducted of a resident family member on 1/24/2023 at 9:20 a.m. and on 2/16/2023 at 10:00 a.m. The LPA requested medical records on 02/09/2023 and received them 02/15/2023. Today, the LPAs interviewed residents at 10:35 a.m. 11:30 a.m., 11:52 a.m., and 12:07 p.m.; and, interviewed staff at 11:10 a.m., 12:06 p.m., 1:30 p.m. and 1:33 p.m. Substantiated Regarding the allegation: Staff did not ensure residents received meals in a timely manner It was alleged that staff failed to provide R1 and R2 with meals in a timely manner. Interviews with R1 and R2 claimed that they temporarily had meals delivered to their room, and indicated that meals had been delivered late. It was noted that on Sunday 1/22/2023, breakfast was served late. The Executive Director noted that they had two call-offs in the kitchen, and claimed there was only one server and one cook for the morning. Staff interviews claimed that breakfast was served from 8:00 a.m. – 9:30 a.m., and the Executive Director believed that all residents received meals before 9:30 a.m. on 1/22/2023. It was communicated that meals were considered ‘late’ after 9:31 a.m. However, additional interviews with dining staff claimed that food trays were delivered to residents whom required tray service at approximately 9:35 a.m. Interviews with residents whom often received meals in the room claimed that meals were often delivered after the stated mealtimes. During a visit conducted on 1/24/2023, the LPA was in R1 and R2’s room, when the lunch trays were delivered. Lunch trays were delivered to R1 and R2’s room at 1:30 p.m. Per the meal schedule, lunch is from 12:00 p.m. – 1:00 p.m. Additional resident interviews were conducted during today’s visit, and residents communicated that in general, food has been served past its slated time as described in dining hours. Based on the information obtained in interviews and observations, there is sufficient evidence to support claims that staff did not ensure residents received meals in a timely manner. This allegation is deemed Substantiated at this time. The following deficiencies were observed (See LIC 9099-D.) and cited from the CA Code of Regulations, Title 22. Failure to correct the deficiencies may result in civil penalties. Exit interview conducted. A copy of the report and appeal rights were provided. CONT - PAGE 2 Regarding the allegation: Staff did not inform authorized representative of resident's injury It was alleged that Resident #1 (R1) suffered an injury, and staff failed to report it to R1’s responsible party. The investigation revealed that on 12/31/2022, R1 contacted a family member and communicated that their arm would not stop bleeding, and claimed that three (3) weeks prior, a staff had allegedly scratched them on the arm, causing a skin tear. Staff allegedly provided R1 with a band-aid, and on approximately 12/30/2022, Resident #2 (R2) took the band-aid off of R1’s arm, in which it caused the skin to rip open. As a result, R1 contacted their family member, whom then took R1 to urgent care on 12/31/2022. The LPA reviewed medical records, and it was documented that on 12/31/2022, R1 shared with the physician that a staff person at the facility had long nails, and had assisted R1 into bed, causing a skin tear on the right upper arm. There were no additional notes in the medical records regarding a band-aid being placed, or that it was removed, which subsequently caused the skin to rip open. Records review noted that R1 was admitted to this facility on 12/15/2021. R1’s admission’s agreement showed that R1 was self-responsible, and R1 did not indicate an emergency contact nor a responsible party. Staff communicated that R1 was independent of care and did not receive assistance outside of housekeeping and laundry services. An interview with R1 revealed that per R1’s recollection, in early December 2022, they required assistance in the evening, and claimed that two staff persons – a male and a female – assisted R1 with getting into bed. R1 claimed that a staff had ‘gouged’ their nails into R1’s right upper arm while lifting R1 up, which caused the skin tear. R1, nor R2, was able to provide the approximate date for this incident. The LPA interviewed staff whom worked the evening and overnight shift and spoke to the staff that responded to R1’s request. Staff claimed that R1 had asked for assistance to get back into bed, and it required the assistance of two staff. Both staff denied claims of harming R1 and denied claims of scratching R1. Staff stated that R1 did not yell or exclaim in pain that something had happened while assisting R1 into bed. Staff could not recall giving R1 a band-aid. R1 was unable to recall details as to whom provided them with the band-aid, but said they got the band-aid from the staff. R1 was unable to recall if they got the band-aid from the staff that evening, or days following the event. Staff interviews revealed that staff were unaware that R1 had sustained a skin tear and staff denied claims that they caused the skin tear. Staff indicated that although they were responsible for R1 and R2's laundering of their linens, staff could not recollect seeing blood or any other foreign substances on their sheets. CONT - PAGE 3 The LPA reviewed incident reports and care notes related to R1 and R2 and did not find documentation to support claims that R1 was observed with an injury. R1 said when they went to urgent care on 12/31/2022, they did not tell the staff why they were going. Based on the information obtained, there is insufficient evidence to support the claim that staff did not inform the authorized representative of R1's injury. Staff claimed they did not know that R1 sustained an injury. As a result, nothing was reported. In addition, R1 and R2 were self-responsible. Although the allegation may have happened or is valid, there is not enough evidence to prove the allegation did or did not occur, therefore the allegation is Unsubstantiated at this time. Regarding the allegation: Staff did not notify authorized representatives of a Communicable disease outbreak It was alleged that staff did not inform an authorized representative of a COVID-19 outbreak. Specifically for R1, it was alleged that R1’s authorized representative was not notified of the COVID-19 outbreak. The investigation revealed that on 01/03/2023, an email was sent out to the responsible parties of the residents regarding active cases of COVID-19 in the community. The Executive Director also noted that the letter was printed for residents and visitors whom came into the facility. Staff interviews indicated that R1 does not have a responsible party or emergency contact, and as a result, notice of the outbreak was provided to R1 and R2. Records review indicated that R1 was admitted to this facility on 12/15/2021. The investigation revealed that a family member of R1 was made aware of the outbreak when they went to visit R1 and R2, and had not received communication about the outbreak prior to coming to the facility. However, R1’s admission’s agreement showed that R1 was self-responsible, and R1 did not indicate an emergency contact nor a responsible party. Staff indicated that R1 was independent of care and did not receive assistance outside of housekeeping services. The Executive Director admitted that they had previously communicated with R1’s family member but said that R1 was ultimately self-responsible. The staff felt that they had fulfilled their obligation in contacting the responsible parties of residents whom have designated an emergency contact or responsible party. Per records review, R1 does not have an identified responsible party. Based on the investigation, there is insufficient evidence to support claims that staff failed to notify R1’s authorized representative of a communicable disease outbreak. The LPA interviewed R1 and R2, and residents noted that they did not have a responsible party on file and confirmed that they were self-responsible. This allegation is deemed Unsubstantiated at this time. CONT - PAGE 4 Regarding the allegation: Staff did not write an incident report of injury It was alleged that staff failed to write an incident report of R1’s injury. The investigation revealed that on 12/31/2022, R1 contacted a family member and communicated that their arm would not stop bleeding, and claimed that three (3) weeks prior, a staff had allegedly scratched them on the arm, causing a skin tear. Staff allegedly provided R1 with a band-aid, and on approximately 12/30/2022, R2 took the band-aid off of R1’s arm, in which it caused the skin to rip open. As a result, R1 contacted their family member, who then took R1 to urgent care on 12/31/2022. An interview with R1 revealed that in early December 2022, they required assistance in the evening, and claimed that two staff persons – a male and a female – assisted R1 with getting into bed. R1 claimed that a staff had ‘gouged’ their nails into R1’s right upper arm while lifting R1 up, which caused the skin tear. R1, nor R2, was able to provide the approximate date for this incident. The LPA interviewed staff whom worked the evening and overnight shift, and spoke to the staff that responded to R1’s request. Staff claimed that R1 had asked for assistance to get back into bed, and it required the assistance of two staff. Both staff denied claims of harming R1 and denied claims of scratching R1. Staff stated that R1 did not yell or exclaim in pain that something had happened while assisting R1 into bed. Staff interviews revealed that staff were unaware that R1 had sustained a skin tear and staff denied claims that they caused the skin tear. The LPA reviewed facility incident reports and care notes related to R1 and R2 and did not find documentation to support claims that R1 was observed with an injury. R1 said that when they went to urgent care on 12/31/2022, they did not tell the staff why they were going. Based on the information obtained, there is insufficient evidence to support the claim that staff knowingly failed to write an incident report. Staff claimed that they did not know that R1 sustained an injury. As a result, nothing was reported. Although the allegation may have happened or is valid, there is not enough evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated at this time. No deficiencies cited at this time. Exit interview conducted. A copy of the report was issued.the state’s words, verbatim · CDSS document, Feb 22, 2023 · control 29-AS-20230123143000

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.2(a)(4) · Plan of correction due date: Feb 27, 2023

87468.2(a)(4) Additional Personal Rights of Residents in Privately Operated Facilities. Residents … shall have ... the following ... rights: To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency ... This requirement is not met as evidenced by: Based on observation and interview, the licensee did not comply with the section cited above, as staff did not provide meals to residents in a timely manner as determined by the posted meal times, which poses a potential personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Feb 22, 2023

Plan of correction: The Administrator agreed to do the following: Communicate a plan of action that details how residents will receive meals in a timely manner, especially for those that receive tray service. Submit plan of action to CCL no later than 2/27/2023.

Type of visit: Case Management - Deficiencies

Licensing Program Analysts (LPAs) Ashley Smith, Esther Cortez, and Angel Ascencio conducted an unannounced Case Management-Deficiencies inspection visit at the facility today due to deficiencies observed during the investigation of complaint control #29-AS-20230123143000. At 11:06 a.m., the office to the Activities Director was unlocked. In the room, the LPAs observed accessible alcohol, cleaning supplies (disinfectant wipes), personal care items (shampoo, soap), and scissors. At 12:10 p.m., the LPAs were touring the memory care unit, and observed sand bags blocking the entrance into the courtyard. The LPAs were able to enter the courtyard; however, the attempted to leave the enclosed courtyard in the memory care unit and discovered that the LPAs was unable to egress back into the facility. The LPAs had to wait for staff to open the door until they were able to get inside the main facility. This is a personal rights violation. The LPA has discussed this concern with the Executive Director on 1/23/2023 and 2/15/2023. Civil penalties assessed in the amount of $250 for a repeat violation. At 12:18 p.m., the LPAs were touring a resident room in the memory care unit. The LPAs observed accessible Lysol spray and Clorox wipes in the resident bathroom cabinet. The following deficiencies were observed (See LIC 809-D.) and cited from the California Code of Regulations, Title 22 and California Health and Safety Code. Failure to correct the deficiencies may result in civil penalties. Exit interview conducted. A copy of the report and appeal rights were provided.the state’s words, verbatim · CDSS document, Feb 22, 2023

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(a)(6) · Plan of correction due date: Feb 22, 2023

87468.1(a)(6) Personal Rights of Residents in All Facilities (a) Residents ... shall have all of the following personal rights: (6) To leave or depart the facility at any time and to not be locked into any room, building, or on facility premises by day or night. This requirement is not met as evidenced by: Based on observation, the licensee did not comply with the section cited above, as the doors to the courtyard in the dementia unit are locked from the inside, thus prohibiting a resident from going into the facility if they're in the courtyard, which poses an immediate personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Feb 22, 2023

Plan of correction: The staff agreed to do the following: 1. Ensure the doors are unlocked by the end of the day. 2. Document how the community will regain compliance with Regulation 87468.1(a)(6). Inform CCL when this has taken place, no later than 2/27/2023, end of day. This is a repeat violation; civil penalty assessed in the amount of $250.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87705(f)(2) · Plan of correction due date: Feb 23, 2023

87705(f)(2) Care of Persons with Dementia. The following shall be stored inaccessible ... : Over-the-counter medication ... or, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants. This requirement is not met as evidenced by: Based on observations, the licensee did not comply with the section cited above as alcohol and cleaning supplies were accessible to residents, which poses an immediate health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Feb 22, 2023

Plan of correction: The staff agreed to do the following: 1. Items were secured upon observation. Staff agreed to provide training regarding regulation 87705(f)(2). Submit sign in sheet no later than 2/27/2023. This is a repeat violation; civil penalty assessed in the amount of $250.

Allegation investigated: Staff do not respond to resident's call for assistance Resident's diapering needs are not met in a timely manner

Licensing Program Analyst (LPA) Ashley Smith a subsequent complaint visit, to deliver findings to the above facility. The met with Executive Director Kortnie Spitznogle and explained the reason for the visit. Entrance interview conducted. The Woodland Hills North Regional Office (RO) received a complaint on 04/25/2022 regarding staff do not respond to residents’ calls for assistance, facility food service is inadequate and resident’s food service is inadequate. CONT on 9099-C Substantiated Regarding the allegation: staff do not respond to residents’ calls for assistance On 04/25/2022, starting at 1:48 p.m., LPA interviewed Resident #1 (R1). Interview with R1 revealed that they have a pendant that continuously breaks. R1 stated, on the days that the pendant is functioning properly, it takes about 20 minutes or more for staff to help. When the pendant is not working, R1 indicated that staff takes the pendant button to fix it but don’t return it for a few days later. Interview with Executive Director (ED) Kortnie Spitznogle on 04/25/2022, starting at 2:45 p.m. revealed that R1 has a working pendant but they continuously push it when help does not arrive. It was communicated that staff had it replaced multiple times because R1 pushes it too hard it breaks. Staff indicated that R1 gets handed a new pendant within a day or two. R1 is on a 2-hour check-up, based on R1’s Needs and Service Plan. In addition, the facility Business Office Manager (BOM) conducts a monthly test on all pendants for servicing. On 2/15/2023, starting at 12:00 p.m., LPA Smith reviewed the SMARTcare Alert Call Button report for Resident #1 (R1). Regarding R1, it was indicated that out of the four (4) instances where R1 pressed their pendant in April 2022, there was one (1) alert that failed to receive a response, and the other three (3) alerts were responded to in a timely manner. However, R1’s pendant button was reportedly to be regularly in disrepair. As such, R1 is unable to call for assistance as needed. As a result, the provided logs may not fully represent the time(s) in which R1 required assistance, or when R1 was without a button and still required assistance. R1 also reported that they would sometimes have to yell for assistance. On 01/23/2023, LPA Ascencio reviewed the SMARTcare Alert Call Button report for three (3) different residents. Review of the call button report revealed that from 11/06/2022 through 12/02/2022, there was seventeen (17) alert button announcements that have elapsed the company’s fifteen (15) minute policy. Further review of the SMARTcare report also revealed that there were five (5) alerts that were never responded to from 11/06/2022 – 12/02/2022. Based on the information from the investigation, there is sufficient evidence to support the claim that staff are not responding to residents’ calls for assistance in a timely manner. A similar complaint was substantiated on 10/25/2022. Based on record review and interview, the allegation is substantiated at this time. CONT 9099-C Regarding the allegation: Resident's diapering needs are not met in a timely manner. On 04/25/2022, starting at 1:48 p.m., LPA interviewed R1. Interview with R1 revealed that when R1 calls staff for toileting needs, staff show up to help 20-30 minutes later, or don’t respond at all. R1 stated they have incontinence issues and would prefer to use the restroom but cannot make it due to their physical limitation. Lastly, R1 added they rely on staff for toileting need and incontinence assistance. On 01/31/2023, starting at 12:05 p.m., review of R1’s Needs and Service Plan revealed that R1’s bathing, toileting, and bowel incontinence require total assistance. Review of Hospice records on 01/31/2023, starting at 12:40 p.m. revealed that on 06/06/2022, Hospice Representative found R1 saturated in urine, dry stool in groin area, and stool under draw sheet. Interview with Hospice Representative on 06/24/2022, starting at 9:45 a.m., confirmed that R1 was found saturated in urine and stool. Although there was insufficient evidence for R1s need not being met, interviews with resident and outside agency revealed that residents diapering need are not met in a timely manner as R1 was found saturated in urine and dry stool in groin area. Therefore, the allegation resident’s diapering needs are not met in a timely manner are substantiated at this time. Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D): Exit interview conducted. Civil penalties assessed. A copy of the report, along with appeal rights, were provided.the state’s words, verbatim · CDSS document, Feb 15, 2023 · control 29-AS-20220425095729

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(2) · Plan of correction due date: Feb 20, 2023

87468.1 Personal Rights of Residents in All Facilities (a)(2) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement is not met as evidenced by: Based on record review and interviews, the licensee did not comply with the section cited above the staff did not respond to R1’s calls for assistance in a timely manner and R1's diapering needs were not met, which poses a potential health, safety and personal risk to persons in care.the state’s words, verbatim · CDSS document, Feb 15, 2023

Plan of correction: The Executive Director agreed to the following: 1. Review policies and procedures around responding to pendants and addressing diapering needs to all staff. Send sign-in sheet to CCL no later than 2/20/2023.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Ashley Smith arrived unannounced to conduct a required annual visit. The LPA met with Executive Director Kortnie Spitznogle and informed them of the reason for the visit. The LPA toured the physical plant areas inside and outside to ensure there are no health and safety hazards and community is in compliance with Title 22 Regulations. Kitchen: At the time of the visit, there was a sufficient supply of two-day perishable and seven-day nonperishable food. The LPA and Executive Director removed items that were perishable items past their expiration date (three pints of yogurt) and items that were not appropriately covered to eliminate concerns of cross-contamination. Staff were able to address this issue upon observation. Technical violation issued. The menu was posted for resident review. Appliances appeared to be in operable condition. Common Areas: The facility is a three-story building. There are resident rooms on all three floors, units are designated for assisted living residents on all three floors and a separate unit on the first floor is designated for residents in the memory care unit. There was a central entry point for universal screening and temperature checks. Staff were observed wearing appropriate face coverings throughout the visit. There was hands-free hand sanitizer interspersed throughout the common grounds. There were no obstructions and/or tripping hazards observed.. The fire extinguishers were charged and last serviced 7/2022. The facility received an annual report on 6/5/2022 in which smoke detectors and carbon monoxide detectors were checked and were in operable condition. At 10:54 a.m., the LPA attempted to leave the enclosed courtyard in the memory care unit and discovered that the LPA was unable to egress back into the facility. The LPA had to wait for staff to open the door until they were able to get inside the main facility. There was also a resident whom was sitting in the courtyard, who would have been unable to get back into the facility unless staff opened the door. This is a personal rights violation. Activities: Planned activities are offered, and the activity schedule was posted. Activity rooms and common spaces appeared clean and in good repair. Rooms: The LPA toured randomly selected rooms in both the memory care and assisted living unit. Rooms appeared clean, well kept, and appropriately furnished. Restrooms: Restrooms on all floors were clean and sanitary. Restrooms were fully stocked with supplies and paper towels. Water temperature was tested on all floors, and water temperature ranged from 113.2 -118.8 degrees Fahrenheit. Outside areas: The LPA observed appropriate outdoor furniture, with a covered shaded area for residents. There was an enclosed patio for residents whom reside in the memory care unit. There are fountains both in the assisted living and memory care patio, but the water was at an appropriate level where it didn’t create a hazard for residents in care. Infection Control: The community has an adequate supply of Personal Protection Equipment (PPE) and can obtain additional supplies. The community's cleaning protocol was sufficient. This facility has records of staff and resident vaccinations. Staff are up to date regarding guidelines pertaining screening recommendations, masking requirements of staff and visitors, and reporting procedures. The community's policies and procedures pertaining to infection control were adequate. The following deficiencies were observed (See LIC 809-D.) and cited from the California Code of Regulations, Title 22 and California Health and Safety Code. Failure to correct the deficiencies may result in civil penalties. Exit interview conducted. A copy of the report and appeal rights were provided.the state’s words, verbatim · CDSS document, Feb 15, 2023

The state marks this report as 4 pages; the online copy we transcribed has 3. You can request the full file from the county licensing office.

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Ashley Smith conducted a Case-Management visit, with the aims of discussing the facility's infection control practices and procedures. This visit was conducted in conjunction with the local and state health department. In attendance included Jonte Vega and Olena Newell from Ventura County Public Health. All parties met with Executive Director Kortnie Spitznogle and Resident Services Director Tahania Gomez and explained the reason for the visit. All parties toured the physical plant areas inside and outside to ensure there are no health and safety hazards and community is in compliance with Title 22 Regulations. The community continues to screen visitors upon entry into the facility. During the tour, recommendations were provided regarding disinfection practices, the availability of hand sanitizer, and additional staff training tools. The cleaning and disinfectant protocol was adequate; however, staff were reminded to observe the contact time needed for surfaces to be properly disinfected. Additional best practices were shared regarding cleaning tools and disinfectant agents used throughout the community. During today's visit, parties discussed the recent outbreak and its impact that it had on visitation, communal dining, and communal activities. The community is not experiencing issues obtaining Personal Protection Equipment (PPE) at this time. The staff requested additional resources around obtaining COVID-19 tests and booster dosages for residents. It was recommended to provide additional staff training pertaining to donning, doffing, and disposal of PPE after usage. Staff were reminded to maintain voluntary compliance regarding reporting requirements to both local public health and the licensing department. No immediate health and safety concerns noted during today’s visit. No deficiencies cited at this time. Exit interview conducted. A copy of the report was issued.the state’s words, verbatim · CDSS document, Feb 10, 2023

Allegation investigated: Resident was injured while in care Resident sustained multiple unwitnessed falls while in care.

Licensing Program Analyst (LPA) Angel Ascencio conducted a subsequent complaint visit to deliver findings for the above allegations. LPA met with Executive Director (ED) Kortnie Spitznogle and explained the reason for the visit. On 03/04/2022, the Department received a complaint regarding allegations of Neglect/Lack of Supervision. It was alleged that Resident #1 (R1) sustained a fracture to the right orbital fracture from an unwitnessed fall and Resident #2 (R2) sustained bruises to eye and forehead due to an unwitnessed fall while in care. The complaint was referred to the Community Care Licensing Investigations Branch (IB) and assigned to Investigator Laura Garcia. On 03/09/2022, from 1:03pm to 3:40pm, Licensing Program Analyst (LPA) Angel Ascencio conducted an unannounced complaint visit to the facility. LPA Ascencio met with Administrator Kortnie Spitznogle at 1:05pm and conducted the entrance interview. Continued on LIC 9099- C Unsubstantiated During the visit, the LPA conducted staff and resident interviews, reviewed resident files, obtained pertinent documents, and toured the facility with the Business Office Manager. The LPA determined further investigation was needed prior to issuing findings. On 04/04/2022, at approximately 5:00pm, Investigator Garcia conducted an interview with the Administrator; on 04/12/2022, from approximately 11:00am to 2:00pm, with Administrator, staff and residents; on 08/16/2022, at approximately 9:43am, with R1’s resident representative; on 08/30/2022, from approximately 11:30am to 12:00pm, with staff. On 12/2/22 at 10:00 a.m., investigator Garcia interviewed a resident care coordinator. On 12/7/22, Investigator Garcia spoke with the resident’s physician’s staff and obtained a copy of R1’s medical condition and progress notes. On 1/4/2023, Investigator Garcia interviewed R1’s physician. Additionally, Investigator Garcia requested and reviewed hospital medical records for R1 and facility file documents related to R1 and R2. On 04/19/2022, the Oxnard Police Department informed Investigator Garcia there were no incident reports or service calls for the facility or concerning R1 and R2. Regarding the allegations “Resident was injured while in care’ and ‘Resident sustained multiple unwitnessed falls while in care’, the complainant’s concern was that the facility staff was not adequately supervising R1 and R2, which resulted in the residents’ experiencing multiple falls in addition to sustaining injuries. The investigator found the following during the course of their investigation. Resident #1 (R1) sustained a right orbital fracture from an unwitnessed fall. Interviews were conducted with R1, R1’s representative, facility Administrator, staff, residents and R1’s physician. R1 stated that the morning shift staff observed R1 with blood on their face, and immediately rendered medical aid and dialed 9-1-1. According to R1, the staff acted accordingly to their medical needs and denied having any complaints against the staff. R1’s representative did not have issues regarding the level of care and supervision provided by the facility staff. R1’s physician stated that although R1 was diagnosed with the early stages of dementia and was legally blind, R1 was able to independently move around, accomplish R1’s personal goals while requiring minimal assistance, which was contrary to R1’s physician’s report and resident assessment, which stated that R1 needed one to one assistance for all activities of daily living, with the exception of eating. The facility is in the process of obtaining an updated physician’s report from the physician. Staff indicated that R1 could care for their own activities of daily living with minimal assistance from staff. There was no evidence provided that R1 required a higher level of care or a one-to-one assist. Continued on LIC 9099 - C Resident #2 (R2) was found on the floor with a bruise on their eye and forehead; and, according to R2, the facility staff conducts their supervision rounds every hour. While attempting to move around in R2’s bed, R2 fell out of bed and sustained minor injuries around eye and forehead. R2 confirmed that the staff immediately dialed 9-1-1, and the paramedics rendered medical aid. Due to minor injuries, R2 declined to be transferred to the hospital and staff continued to monitor R2 every half hour. R2 denied having any complaints against the level of care provided by facility staff or issues of neglect or lack of supervision. Based on statements and documentation provided, the Department does not have sufficient evidence to determine that there was negligence or lack of supervision on behalf of the facility staff. Although both R1 and R2 did suffer an injury while at the facility, there is insufficient evidence to conclude that it was due to neglect on the part of facility staff. In addition, although both residents sustained unwitnessed falls while in care, there is insufficient evidence to conclude that the falls were as a result of staff negligence. Therefore, the allegations that ‘Resident was injured while in care’ and ‘Resident sustained multiple unwitnessed falls while in care’ are deemed as unsubstantiated at this time. Exit interview, copy of report was issued.the state’s words, verbatim · CDSS document, Jan 31, 2023 · control 29-AS-20220304165304

Allegation investigated: Licensee is not keeping facility free of rodents

Licensing Program Analysts (LPAs) Ashley Smith and Angel Ascencio arrived unannounced to conduct an initial complaint visit. The LPAs met with Executive Director (ED) Kortnie Spitznogle and explained the reason for the visit. Today, the LPAs toured the kitchen at 10:15 a.m., interviewed staff at 10:20 a.m., 12:23 p.m., 1:31 p.m., 1:35 p.m., and interviewed residents at 12:30 p.m., 12:35 p.m., 12:56 p.m., 1:40 p.m., and 2:05 p.m. Regarding the allegation, it is alleged that there were rat droppings in the kitchen, specifically on the floor, countertops, and kitchen equipment. The ED admitted that the facility has an issue with rats in the kitchen. The ED mentioned that a staff person had observed a rat coming through the vents in the kitchen. The ED claimed that the pest control company Terminex has provided monthly service to the facility since October 2022 and noted that the company recently came out on 1/13/2023 and submitted a proposal for a concentrated treatment in the kitchen only. Substantiated However, at 10:20 a.m., the LPAs and the Executive Director (ED) toured the kitchen area of the facility. The LPAs and the ED observed rat droppings on the floor, on top of kitchen counters, and on top of kitchen equipment. Information obtained from interviews supported claims that persons have either observed rat droppings in the kitchen or have heard about the presence of rats in the kitchen. This facility was recently cited for an allegation of rats in the facility on 10/13/2022. The ED admitted that the rat problem has been a chronic issue. Based on observation and interview, the above allegation is Substantiated at this time. Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 9099-D). Exit interview conducted. Appeal Rights Discussed. A copy of the report was provided. Civil penalty assessed.the state’s words, verbatim · CDSS document, Jan 23, 2023 · control 29-AS-20230119090203

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87555(b)(27) · Plan of correction due date: Jan 24, 2023

87555(b)(27) General Food Service Requirements. All kitchen areas shall be kept clean and free of litter, rodents, vermin and insects. This requirement is not met as evidenced by: Based on interviews and observations, the licensee did not comply with the section cited above, as there were rodent droppings observed in the kitchen and staff admitted that the facility had an issue with rodents in the kitchen, which poses and immediate health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Jan 23, 2023

Plan of correction: The Executive Director agreed to do the following: 1. Submit a written plan of action, detailing how the facility will maintain compliance with the regulation. Indicate the steps the facility is taking to manage the pest concern on a daily basis. Submit Plan of Action no later than 1/24/2023, end of day. The facility was cited for this regulation on 10/13/2022, civil penalty of $250 assessed.

Type of visit: Case Management - Deficiencies

Licensing Program Analysts (LPAs) Ashley Smith and Angel Ascencio conducted an unannounced Case Management-Deficiencies inspection visit at the facility today due to deficiencies observed during the investigation of complaint control # 29-AS-20230119090203. At 12:20 p.m., the LPAs observed a fountain the courtyard in the memory care unit. The fountain had approximately two (2) inches of standing water at the bottom of the fountain. At 12:22 p.m., the LPAs attempted to leave the enclosed courtyard in the memory care unit and discovered that the LPAs were unable to egress back into the facility. The LPAs had to wait for staff to open the door until they were able to get inside the main facility. This is a personal rights violation. At 12:47 p.m., the LPAs observed the 3rd floor theater room, and identified that a screen was missing from a window. The window screen was on the floor. As a result, the window leads to an enclosed balcony area. At 12:49 p.m., the LPAs observed the staff break room. There was an accessible knife observed in a drawer. At 12:52 p.m., the LPAs observed accessible gardening supplies (soil) and tools in the courtyard. At 12:53 p.m., the LPAs observed a fountain the main courtyard. The fountain had approximately four (4) inches of standing water at the bottom of the fountain. This is a zero-tolerance violation, which results in a civil penalty in the amount of $500. Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D): Exit Interview Conducted. Appeal Rights Discussed. A Copy of the Report Issued.the state’s words, verbatim · CDSS document, Jan 23, 2023

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87307(e) · Plan of correction due date: Jan 24, 2023

87307(e) Personal Accommodations and Services. Facilities providing services to residents who have physical or mental disabilities shall assure the inaccessibility of fishponds, wading pools, hot tubs, swimming pools, or similar bodies of water...through fencing, covering or other means. This requirement is not met as evidenced by: Based on observation, the licensee did not comply with the section cited above as the facility had water fountains in the courtyard and in front of the building filled with standing water, which poses an immediate health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Jan 23, 2023

Plan of correction: The ED agreed to do the following: 1. Water features will be drained of water by end of the day, 1/23/2023. 2. Rocks would be placed in the water features to ensure water depth does not pose a hazard to residents in care. Send photos once completed. This is a zero tolerance violation; civil penalty in the amount of $500 assessed.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87309(a) · Plan of correction due date: Jan 23, 2023

87309(a) Storage Space. Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. This requirement is not met as evidenced by: Based on observation, the licensee did not comply with the section cited above, as a knife was accessible in the staff room and accessible gardening supplies and tools in the courtyard, which poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jan 23, 2023

Plan of correction: The ED agreed to secure the items by the end of the day, 1/23/2023.

From the deficiency page — Deficiency type: Type A · Section cited: HSC 87468.1(a)(6) · Plan of correction due date: Jan 24, 2023

87468.1(a)(6) Personal Rights of Residents in All Facilities (a) Residents ... shall have all of the following personal rights:(6) To leave or depart the facility at any time and to not be locked into any room, building, or on facility premises by day or night. This requirement is not met as evidenced by: Based on interviews, the licensee did not comply with the section cited above, as the exterior doors to the courtyard in the memory care unit are locked from the inside, which poses an immediate personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Jan 23, 2023

Plan of correction: The ED agreed to do the following: 1. Submit a statement, detailing how the community will regain compliance with Regulation 87468.1(a)(6). Submit statement to CCL no later than 1/24/2023, end of day.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87303(c) · Plan of correction due date: Jan 24, 2023

87303(c) Maintenance and Operation. All window screens shall be clean and maintained in good repair. This requirement is not met as evidenced by: Based on observation, the licensee did not comply with the section cited above, as the window screen in the theater room was missing, which poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jan 23, 2023

Plan of correction: The ED agreed to do the following: 1. Repair or replace the screen on the window no later than 1/24/2023.

Type of visit: Case Management - Other

Licensing Program Analysts (LPAs) Ashley Smith and Angel Ascencio conducted an unannounced Case Management - Other visit to the above facility. The purpose of today's visit to ensure an excluded individual is not employed at the facility. The LPAs met with Executive Director Kortnie Spitznogle and explained the reason for the visit. During today's visit, the LPAs inquired as to whether Staff #1 (S1) is currently employed at the facility. The Business Office Manager confirmed that S1 had submitted an application but was not actively working at this facility nor was S1 ghired. The Woodland Hills North Regional Office reviewed the legal case and the individual’s history and the Stipulation/Decision and Order excluded the individual for life. The individual is not eligible to be licensed, reside or work in a facility. The Decision and Order was served to the licensee and S1 via certified mail on 01/06/2023 and was effective as of 01/17/2023. The ED confirmed that they had received documentation regarding S1, which confirmed that S1 could not be employed at this facility. In addition, LPA obtained copies of the staff roster to verify that S1 is not employed at the facility. Exit interview conducted. A copy of report issued.the state’s words, verbatim · CDSS document, Jan 23, 2023

Allegation investigated: Staff are not meeting residents’ dietary restrictions

Licensing Program Analyst (LPA) Angel Ascencio conducted a subsequent visit to the facility above to deliver findings. LPA Ascencio met with Business Office Manager (BOM) Cynthia Garcia 2:27 pm. Administrator Kortnie Spitznogle was not able to be present. Entrance interview conducted. On 10/06/2022, the Department received a complaint alleging that staff are not meeting resident’s dietary restrictions. During a facility tour on 10/13/2022, LPA Ascencio observed a dietary list, in the kitchen, that had the restrictions or modified diets for each resident at the facility. On 10/13/2022 and 01/04/2023, LPA Ascencio conducted eight (8) resident interviews. Interviews with residents revealed that most of the time, residents are unaware of what is being served during mealtimes. Residents stated that the facility staff know they have dietary restriction yet don’t provide alternative options for food items. Continued on LIC 9099 - C Substantiated Further interviews revealed that some of the residents’ dietary need are as follows: low sodium, heart health, and diabetic. Various resident stated they have restrictions on diets, but facility staff continues to provide every resident with pastas, burgers, sandwiches, fries, fried foods, and pancakes during mealtimes. There are days that there are healthy options or they get restrictions right, but most of the time its food items we know we cannot eat, we cannot have or it bad. Interviews with six (6) staff members on 10/13/2022 and 01/04/2023, revealed that some staff claim they do their due diligence in ensuring that the residents dietary needs are met. Staff interviews also indicated that due to an inadequate supply of perishable and nonperishable foods as it relates to the daily menus, staff believe they are unable to meet resident dietary needs as prescribed for low sodium, heart health and diabetic. A similar complaint, reported to the Department on 10/12/2022 relating to food quality and requirements, was substantiated. Based on evidence gathered throughout the investigation, the allegation is deemed substantiated at this time. Once the resident or visitor comes up to the front entrance, there is a phone number that they can call, and a staff member will open the door. Interview with Resident #1 (R1) on 10/14/2022 revealed that R1 has had no problem leaving the facility after reception was done for the day at 5:00 p.m. R1 lastly added that they have heard of other residents and visitors trying to get into the facility after hours and having to wait due to a shortage of staff in the evening. Additional interviews with residents on 10/13/2022 and 1/4/2023 revealed that they don’t feel like they are locked in the facility, but the main problem is someone not opening the main door after hours. Interview with R2, on 10/13/2022 starting at 1:40 p.m., revealed that R2 was able to leave the facility without any problem but had to wait 20-30 minutes outside on various occasions before the door was opened for R2. Although the allegation has been determined to be unsubstantiated, a conversation was held with the Business Office Manager during the exit interview of today’s visit. LPA stressed the importance of knowing clients’ personal rights and having sufficient staff to address the needs of residents. BOM stated they will continue to hire staff. Copy of the report provided to Administrator via email.the state’s words, verbatim · CDSS document, Jan 6, 2023 · control 29-AS-20221006083747

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87555(b)(7) · Plan of correction due date: Jan 13, 2023

87555 General Food Service Requirements (b) (7) Modified diets prescribed by a resident's physician as a medical necessity shall be provided. This requirement is not met as evidence by: Based on interviews, the licensee did not comply with the section cited above as modified diets prescribed by resident physicians have not been followed which poses a potential health, safety and personal rights risk to resident in care.the state’s words, verbatim · CDSS document, Jan 6, 2023

Plan of correction: Administrator will conduct kitchen staff training on modified diets. Administrator will provide residents with modified diets and alternative food option to adhere with the physician’s order. Administrator will submit training to LPA by 1/13/2022.

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Angel Ascencio arrived unannounced to conduct a Case Management – Other visit. The LPA met with Business Office Manger (BOM) Cynthia Garcia and explained the reason for the visit. Executive Director Kortnie Spitznogle was not able to attend. Entrance interview conducted. This visit was regarding ongoing concerns related to the current Coronavirus (COVID-19) Outbreak. Community Care Licensing (CCL) received a faxed incident report from this facility on 12/29/2022, indicating that a resident had tested positive for COVID-19 on 12/26/2022. The Department obtained a letter dated 12/30/2022 that was addressed to the residents and families of this facility, indicating that the facility had ceased communal dining and group activities due to the rising cases of COVID-19. Although the letter indicated that this plan had been discussed with the local health department and CCLD, current guidance as detailed in Provider Information Notices (PINs) and the local health department does not support the above-mentioned plan. PIN 21-49 ASC, which was released 11/17/2021, indicates that ‘Facilities may not prohibit residents from eating in the same room and/or at the same table, unless those residents are on isolation or quarantine precautions. Facilities may not prohibit residents from participating in group activities so long as there is appropriate hand hygiene, unless those residents are on isolation or quarantine precautions…. Residents who are not on isolation or quarantine precautions retain the right to participate in communal dining and group activities, regardless of their vaccination status. However, during an outbreak in the facility, the local public health department may require cessation of all communal dining and group activities until transmission has been contained.’ The investigation revealed that at this time, the local health department did not require this facility to cease communal dining and/or group activities. Per guidance from the Department, licensees must uphold the personal rights of residents by allowing residents and visitors to participate in communal dining and activities. Lastly, the investigation revealed that whereas the Administrator initially informed Ventura County Health Department (VCPH) about the initial cases of COVID-19, but no communication since the initial discussion, and VCPH was unaware of the cases of COVID-19 until they were informed by CCL. This is a repeat violation. A civil penalty of $250 is also assessed. Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D): Exit interview conducted. Civil penalties assessed. A copy of the report, along with appeal rights, were provided.the state’s words, verbatim · CDSS document, Jan 6, 2023

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.2(a)(6) · Plan of correction due date: Jan 9, 2023

87468.2(a)(6) Additional Personal Rights of Residents in Privately Operated Facilities. Residents …. shall have all of the following personal rights: To make choices concerning their daily lives in the facility. This requirement is not met as evidenced by: Based on interview, the licensee did not comply with the section cited above, as the facility has not allowed residents whom are not on isolation or quarantine precautions to participate in communal dining or activities, which poses an immediate personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Jan 6, 2023

Plan of correction: The Administrator agreed to do the following: 1. Review PIN 21-49 ASC and submit a statement of understanding, indicating how the facility will maintain voluntary compliance. Submit statement by 1/9/2023. 2. Submit an updated letter to residents and responsible parties, indicating the plan moving forward as it relates to the current outbreak. Submit the letter by 1/9/2023

From the deficiency page — Deficiency type: Type A · Section cited: CCR87211(a)(2) · Plan of correction due date: Jan 9, 2023

87211(a)(2) Reporting Requirements. Occurrences, such as epidemic outbreaks, poisonings, catastrophes or major accidents which threaten the welfare, safety...shall be reported within 24 hours either by telephone or facsimile to the licensing agency and to the local health officer when appropriate. This requirement is not met as evidenced by: Based on interview, the licensee did not comply with the section cited above as the facility did not report an outbreak to the appropriate agencies in a timely manner, which poses an immediate health, safety and personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jan 6, 2023

Plan of correction: The Administrator agreed to do the following: 1. Report the cases to VCPH by 1/9/2023 2. Conduct training regarding reporting requirements and documentation. Submit training documents to CCL no later than 1/13/2023

Allegation investigated: Staff did not respond to resident's calls for assistance. Staff are not providing residents with food of good quality.

Licensing Program Analyst (LPA) Angel Ascencio conducted a subsequent visit to the above facility. LPA met with Executive Director Kortnie Spitznogle at 12:35 p.m. Entrance interview conducted. The Woodland Hills North Regional Office (RO) received a complaint on 10/12/2022 regarding staff did not respond to residents's calls for assist and staff are not providing residents with food of good quality. During Resident #1 (R1) interview on 10/13/2022 starting at 3:06 p.m., R1 stated that their pendant was not working for awhile and that it took about thirty (30) minutes for a staff member to respond. R1 added they had a wrist bracelet but was changed to an necklace pendant. R1 also added that the average time to wait for care staff to assist them was about ffteen (15) - twenty (20) minutes long. R1 added, there was once incident in early October that R1 had to urinate but staff never showed up. R1 had an incontinence accident on this occacion. On 10/25/2022, starting at 3:02 p.m., LPA reviewed the SMARTcare Alert Call Button report for R1. Continued on LIC 9099 - C Substantiated Review of the SMARTcare Report revealed from 09/7/2022 through 09/30/2022 there was fifty (50) alert button announcements that had elapsed the companies fifteen (15) minute policy. Further review of the SMARcare report also revealed that there was eleven (11) alerts that were never responded to the time frame of 09/7/2022 - 09/30/2022. Based on record review and interview, the allegation is substantiated at this time. Regarding the allegation of Staff are not providing residents with food of good quality. Interview with three (3) residents on 10/13/2022 starting at 3:20 p.m., one (1) resident on 10/18/2022 starting at 8:11 a.m., and three (3) resident on 10/25/2022 starting at 2:50 p.m., it was revealed that the food is not great. Residents added that the meals are not consistent with variety and with no consideration to the age group being served. Residents also said that the quality and quantity of food doesn't meet up to the standards of what the resident should be having. Residents stated they have been served, corndogs, sandwiches, stale bread with their hamburgers, burnt beans, uncooked meat, uncooked pancakes, frozen meats, chili beans and Dorito floats. Several residents had taken pictures of the various meals that have been served and sent LPA a copy of the pictures. Interview with four (4) staff on 10/13/2022, 10/19/2022, and 10/25/2022 revealed that the food is horrible here. Staff stated what is on the menu is different from what they are receiving. There has been various complaint about food and some resident get upset because they don't have it. Staff included that there are some residents that are refusing to eat in the dinning room because the food being served is not of food quality. Staff provided LPA with photographs of meals being served to residents that included burn beans, corn dogs, onion rings, and crushed-up Doritos on a plate with meat. Review of Staff #1(S1) files revealed that S1 has been the head cook since August 2022. S1 was hired in June 2022 initially as the Activities Director but was promoted to Dinning Service Director. LPA noted that S1 had previously worked as a prep-cook at another assisted facility. LPA requested and received the required annual training for S1 but had no qualified formal training in dinning services. Based on record review, interviews and observation, the allegation, staff are not providing residents with food of good quality is deemed substantiated at this time. 2 citations were issued during today's visit. Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 9099-D): Exit interview conducted, today's report and appeal rights were reviewed and emailed to ED.the state’s words, verbatim · CDSS document, Oct 25, 2022 · control 29-AS-20221012131509

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(2) · Plan of correction due date: Nov 4, 2022

87468.1 Personal Rights of Residents in All Facilities (a)(2) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement is not met as evidenced by: Based on record review and interviews, the licensee did not comly with the section cited above the staff did not respond to resident's calls for assistance which poses a potential health, safety and personal risk to persons in care.the state’s words, verbatim · CDSS document, Oct 25, 2022

Plan of correction: Admin will provide training on Personal Rights and Process and Procedure on the call monitoring system for time effeciency to staff. Admin will provide copy of training material and staff attendees to LPA via email. angel.ascencio@dss.ca.gov

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87555(a) · Plan of correction due date: Nov 4, 2022

87555 General Food Service Requirments (a) The total daily diet shall be of the quality and in the quantity necessary to meet the needs of the residents and shall meet the Recommended Dietary Allowances of the Food and Nutrition Board of the National Research Council. All food shall be selected, stored, prepared and served in a safe and healthful manner. This requirement is not met as evidenced by: Based on interviews, record review and observation, the licensee did not comply with the section cited above as the facility has not been meeting the needs of the residents in quality and quantity which poses a potentail health, safety and personal rights risk to person in care.the state’s words, verbatim · CDSS document, Oct 25, 2022

Plan of correction: Admin will conduct ongoing, monthly meetings with the residents to address the quality of food When foods items are not accesible, Admin will delegate with coorporate to find other healthier and alternatives foods for residents. Admin will provide an updated menu to LPA with healthier, viarety choice of foods.

The state marks this report as 4 pages; the online copy we transcribed has 3. You can request the full file from the county licensing office.

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Angel Ascencio conducted a Case Management visit at the above facility. LPA met with Executive Director (ED) Kortnie Spitznogle at 12:30 p.m. During a facility tour on 10/13/2022, LPA observed two (2) housekeeping staff that did not wear face coverings while in the facility, as required by the CA Dept. of Public Health Guidance on the Use of Face Coverings issued June 18, 2020 and updated November 16, 2020, and an individual mask exception did not apply. LPA advised ED that all staff are required to wear a mask. Housekeepers proceeded to wear a face cover. On 10/25/2022 , starting around 12:35 p.m., LPA observed two (2) kitchen staff not wearing face. LPA met with ED and explained mask requirements are mandatory. That same day, at 12:24 p.m., LPA observed a fire exit door on the north-east stairwell, propped open with a door wedge. Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D): Exit interview conducted, today's report and appeal rights were reviewed and emailed to ED.the state’s words, verbatim · CDSS document, Oct 25, 2022

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87203 · Plan of correction due date: Oct 26, 2022

87203 Fire Safety All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic. This requirement is not met as evidenced by Based on observation, the Licensee did not comply with the section cited above as LPA observed 2 fire exit door at the stairwell being propped open with a door wedge which poses an immidiate health, safety and personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Oct 25, 2022

Plan of correction: ED will contact local Fire Marshal to conduct all staff training on regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic. ED will submit the training materials and attendees to CCL.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87468.1 · Plan of correction due date: Oct 26, 2022

87468.1 Personal Rights of Residents in all Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement is not met as evidenced by: Based on observation the licensee did not comply with the section cited above as on 10/13/2022 and 10/25/2022,two (2) housekeepers and 2 kitchen staff were observed without a face mask upon arrival which poses an immediate health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Oct 25, 2022

Plan of correction: ED will conduct all staff meeting regarding CA Dept. of Public Health Guidance on the Use of Face Coverings issued June 18, 2020 and updated November 16, 2020. ED will submit the training materials and attendees to CCL.

Allegation investigated: Staff did not keep facility free from pests. Resident’s bathroom is in disrepair due to staff not repairing.

Licensing Program Analyst (LPA) Angel Ascencio conducted an unnanouced, initial complaint visit to the facility above, LPA met with Executive Director Kortnie Spitznogle at 1:16 p.m. Entrance interview conducted. The Woodland Hills North Regional Office (RO) received a complaint on 10/12/2022 regarding staff did not keep facility free from pest and resident's bathroom is in disrepair due to staff not repairing. On 10/13/2022, LPA Ascencio conducted an interview with Executive Director (ED) Kortnie Spitznogle at 1:16 pm. ED Spitznogle stated they did find a mouse in the kitchen. ED added that a company came to fix teh air conditioning and left the ceiling hatch open. ED added that they placed traps in the kitchen and were able to catch the vermin in the kitchen. ED also stated they have a company EcoLabs and Teminex coming to the facility to spray the community and get rid of any other vermin if any are found. Based on interview conducted, the allegation staff did not keep teh facility free from pest is deemed Substantiated at this time. Continued on LIC 9099 - C Substantiated Regarding the allegation, Resident’s bathroom is in disrepair due to staff not repairing. LPA conducted interview with ED Spitznogle at 1:16 p.m. Interview with ED revealed that Resident #1 (R1) has been having problems with their toilet. Our interim Maintenance Director has been in R1's to fix the the restroom and has changed valved but it still not working properly. ED stated at this moments R1 walked down the hall to use the public restroom. Interview with R1, starting at 04:23 p.m. revealed that the restroom has not been working for one (1) week. The staff have come to my room about two(2) - three(3) times already but have yet to fix it. R1 stated they have been walking to use the public restroom halfway down the hallway. LPA observed R1's bathroom at 04:28 p.m. and observed the water in the toilet not completely flush down. R1 stated they have yet to received an update or notice on when the toilet will get fixed. R1 has heard from other staff members that Saturday a plumber will be at the building to fix the issue. Based on observation, and staff and resident interviews, the allegation resident's bathroom is in disrepair due to staff not repairing is deemed Substantiated at this time. 2 citations were issued during today’s visit. The following deficiencies were observed (See LIC 809-D.) and cited from the California Code of Regulations, Title 22 and California Health and Safety Code. Failure to correct the deficiencies may result in civil penalties. Exit interview conducted. A copy of the report and appeal rights were provided to admin via email.the state’s words, verbatim · CDSS document, Oct 13, 2022 · control 29-AS-20221012131509

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87555(b)(27) · Plan of correction due date: Oct 14, 2022

87555 General Food Service Requirements (b)(27) All kitchen areas shall be kept clean and free of litter, rodents, vermin and insects. Based on interviews, the Licensee did not comply with the section cited above as the ED stated they did find rodents in the kitchen which poses and immediate health, safety and personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Oct 13, 2022

Plan of correction: Admin has contracted a company to remove the rodents. Admin will provide invoices of recent pest control visit to CCL by 10/14/22.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Oct 21, 2022

87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. Based on interviews and observation, the licensee did not comply with teh section cited above as R1's toilet has not been working for 1 week which poses a potential health, safety and personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Oct 13, 2022

Plan of correction: Admin will contract a repair company to fix R1's restroom. Admin will provide invoice of repair of R1's toilet.

The state marks this report as 5 pages; the online copy we transcribed has 4. You can request the full file from the county licensing office.

Allegation investigated: Facility has scabies outbreak

Licensing Program Analyst (LPA) Kelly Dulek arrived at the facility at 11:12 AM to conduct a subsequent complaint investigation for the allegation listed above. LPA met with facility Executive Director Kortnie Spitznogle. Entrance interview conducted. During today's visit, LPA Dulek interviewed Administrator at 11:15AM, staff at 11:54AM, and LPA reviewed and obtained copies of pertinent documents. Previously during a subsequent complaint inspection conducted on 04/25/2022, LPA Ascencio toured the facility at 12:30PM, and LPA Dulek requested pertinent documents, however the documents were unavailable at the time of the visit. During an initial virtual complaint visit, which took place on 09/21/2020, LPA Dulek conducted a telephone interview with the RCD and requested pertinent documents, which were not received. During unrelated complaint visits conducted in person at the facility, LPA Dulek conducted staff and resident interviews related to this complaint. The following was then determined: Substantiated It was alleged that the facility has a scabies outbreak. Interview revealed that there were 4 residents in the facility that had been diagnosed with scabies during the time period of the complaint allegation. Review of records for Resident #1 (R1), whom the complaint allegation references, did have a diagnosis of scabies as of 07/01/2020. R1 was prescribed medication for the diagnosed case of scabies. Additional record review revealed this scabies case was not reported to CCL or to Ventura County Public Health, per regulation. Based on record review and interview, the allegation that "facility has a scabies outbreak" is deemed SUBSTANTIATED at this time. Pursuant to Title 22, California Code of Regulations, the following deficiency is cited (refer to LIC 9099-D.) Executive Director was informed that civil penalties may be assessed at a later date based on Health and Safety Code 1569.49(f). Exit interview conducted, appeal rights discussed, and a copy of this report was issued via email. Regarding the allegation "Resident suffered multiple falls resulting in injuries:" Record review revealed that Resident #1 (R1) had fallen six (6) times during the time period of 06/17/2020 - 08/21/2020. Review of R1's physician's report indicates R1 is non-ambulatory with a diagnosis of dementia. R1 was able to ambulate using a wheelchair. R1 was noted to be able to follow instructions, able to transfer themself and able to communicate their needs. Record review did not reveal that R1 was a fall risk. Although it is possible that R1 had a change of condition, as the care notes dated 07/06/2020 after R1 had returned from the hospital, indicated R1 was "having a hard time walking." No new care assessment or physician's report was completed, so it is unclear whether R1 did have a change of condition or not. Resident Assessment review revealed R1 was independent in most ADLs, including transfers and did not require an escort to ambulate. While record review did indicate R1 had fallen multiple times, there was no documented evidence indicating the falls were sustained as a result of lack of care and supervision. As thus, although the allegation may be valid, based on record review, at this time there is insufficient evidence to prove a violation occurred; therefore the allegation that "resident suffered multiple falls resulting in injuries" is deemed UNSUBSTANTIATED at this time. Regarding the allegation "Staff did not bathe resident:" During the complaint investigation, LPA reviewed records for R1 and interviewed staff and residents. R1 no longer resided at the facility at the time of the interviews, however resident interviews revealed that showers are currently offered and assisted with on time and on schedule. Record review for R1 indicated R1's needs and service assessment did not include shower assistance, nor did R1's resident pre-placement appraisal indicate shower assistance was needed. However, physician's report did indicate R1 required bathing assistance. Care notes reviewed indicate R1 was showered on 08/13/2020 and 08/15/2020. R1 was hospitalized then R1 moved out of the facility as of 08/21/2020. There was no record of how often R1 was to be assisted with bathing. As thus, although the allegation may be valid, based on record review and interview, at this time there is insufficient evidence to prove a violation occurred; therefore the allegation that "staff did not bathe resident" is deemed UNSUBSTANTIATED at this time. Regarding the allegation "staff illegally evicted resident:" It was alleged that when family arrived at the facility, R1's belongings were packed up and R1 did not return to the facility. Emails between Pacifica Senior Living management members and R1's family were reviewed during the complaint process. Emails reviewed indicate management staff had been in communications Report Continued on LIC 9099-C with R1's family and that alternate placement suggestions had been made for R1's changing care needs 2 days prior to R1 moving out of the facility. The day prior to R1 moving out of the facility, management had exchanged emails indicating "we have not issued a 30 day notice at this time." However, the management team had discussed R1's care needs. Emails indicate R1's family had asked Pacifica to communicate with alternate placement, with the hopes R1 could move to another facility. Care notes indicate R1 moved out of the facility, however it is unclear whether the facility moved the resident out or if the facility evicted R1. Interview with staff revealed that the resident was not evicted to their knowledge, however additional communications with R1's family may have occurred with the Executive Director employed with the facility at that time. The Executive Director left employment effective 08/27/2020 and therefore was unavailable to interview regarding this complaint. Although the allegation may be valid, based on record review and interview, at this time there is insufficient evidence to prove a violation occurred; therefore the allegation that "staff did not bathe resident" is deemed UNSUBSTANTIATED at this time. Regarding the allegation "Staff did not administer medications as prescribed:" It was alleged that R1's 6:00 medications were not administered on time, as they were administered at 06:20. R1 was no longer residing at the facility and had taken their medications with them and therefore unable to be audited during the complaint process. During the visit on 09/23/2022, LPA conducted a medication audit for 3 residents. All 3 of 3 residents' medications reviewed were administered as prescribed. Care notes for R1 did not indicate any discrepancies in medications administered. Communication between the facility and R1's physician was reviewed and did not indicate any medication discrepancies. On 08/14/2020 there was a change in orders indicating medication Quetiapine 25mg was changed from TID to BID (8am and 12noon) and Quetiapine 50mg QPM. However no documentation was able to be reviewed regarding times the medications were administered, nor was there specific dates indicated in the allegation to review what the doctor's orders were at that time. Interviews revealed medications are given on time as prescribed. Although the allegation may be valid, based on record review and interview, at this time there is insufficient evidence to prove a violation occurred; therefore the allegation that "staff did not administer medications as prescribed" is deemed UNSUBSTANTIATED at this time. Exit interview conducted. A copy of the report was provided via email.the state’s words, verbatim · CDSS document, Sep 23, 2022 · control 29-AS-20200910115337

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(2) · Plan of correction due date: Sep 23, 2022

87211 Reporting Requirements (a)(2) Occurrences, such as epidemic outbreaks, ...or major accidents which threaten the welfare, safety or health of residents...shall be reported within 24 hours either by telephone or facsimile to the licensing agency This requirement is not met as evidenced by: Based on interview and record review, the licensee did not comply with the section cited above, as R1 was diagnosed with scabies, yet CCL was not notified, which poses a potential personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Sep 23, 2022

Plan of correction: Administrator has agreed to submit Incident Reports to CCL in the timeline reflected in section 87211. Administrator indicated a training was conducted in May 2022 regarding reporting requirements and proof was sent to CCL at that time. POC cleared

Allegation investigated: Insufficient staffing Resident's incontinence needs not being met

Read the state’s words on page 2 of the record →

Type of visit: Case Management - Incident

Read the state’s words on page 2 of the record →

Allegation investigated: Facility did not meet reporting requirements

Read the state’s words on page 2 of the record →

Allegation investigated: Facility staff did not provide new facility with resident's personal belongings. Facility staff did not clean resident's room. Facility did not provide resident with proper refund.

Read the state’s words on page 2 of the record →

Allegation investigated: Staff are not wearing masks

Read the state’s words on page 2 of the record →

Type of visit: Case Management - Incident

Read the state’s words on page 2 of the record →

Allegation investigated: Facility staff is not dispensing medication as prescribed

Read the state’s words on page 2 of the record →

Allegation investigated: Personnel were not trained for the job(s) assigned to them. Facility did not maintain adequate staffing to meet resident(s) needs. Resident(s) call lights are not being answered.

Read the state’s words on page 2 of the record →

Allegation investigated: Staff failed to observe changes in resident's health Facility has ant infestation

Read the state’s words on page 2 of the record →

Allegation investigated: Resident's apartment is not kept at a comfortable temperature

Read the state’s words on page 2 of the record →

Allegation investigated: Facility failed to handle outbreak appropriately.

Read the state’s words on page 2 of the record →

Allegation investigated: Facility has no Administrator

Read the state’s words on page 2 of the record →

Type of visit: Required - 1 Year

Read the state’s words on page 2 of the record →

Allegation investigated: Staff isolating residents from authorized representatives while in care Staff emotionally abuses residents while in care Staff creates fictitious medical reasons for residents without authorization Staff mishandles resident while in care Staff retaliates against residents while in care

Read the state’s words on page 2 of the record →

Allegation investigated: Resident sustained bed sore while in care Resident not administered medication as prescribed Staff left resident in soiled clothing for extended period of time Facility staff not responding to resident's call button Facility staff not safeguarding resident’s property

Read the state’s words on page 2 of the record →

Allegation investigated: Neglect/Lack of Supervision: Resident #1 (R1) sustained multiple pressure injuries while in care Neglect/Lack of Supervisiion: Facility staff did not seek medical attention for Resident #1 (R1) Staff mismanaging resident’s medication Staff not responding to resident’s call button in a timely manner Resident was left in soiled diaper for extended period of time Staff not providing adequate food service to resident Staff did not safeguard personal belongings

Read the state’s words on page 2 of the record →

Allegation investigated: Facility did not provide adequate staff to meet resident needs Facility staff did not provide a sanitary environment for residents Resident requires a higher level of care

Read the state’s words on page 2 of the record →

Allegation investigated: Staff speaking inappropriately to resident while in care Staff failed to effectively communicate with the residents while in care Unqualified staff is providing care and supervision Facility is not providing residents with adequate food Residents are left in soiled diapers for extended periods of time

Read the state’s words on page 2 of the record →

Allegation investigated: Resident is left in soiled diapers for extended periods of time Staff did not give medication to resident

Read the state’s words on page 2 of the record →

Type of visit: Case Management - Deficiencies

Read the state’s words on page 2 of the record →

Allegation investigated: Resident sustained an unexplained injury while in care

Read the state’s words on page 2 of the record →

Allegation investigated: Staff inappropriately restrained resident while in care.

Read the state’s words on page 2 of the record →

Allegation investigated: Staff are not responding to residents calls for assistance in a timely manor

Read the state’s words on page 2 of the record →

Allegation investigated: Resident sustained unexplained injuries while in care

Read the state’s words on page 2 of the record →

Allegation investigated: Staff are overmedicating residents. Medications are not properly stored and locked. Staff handling residents in rough manner causing skin injury.

Read the state’s words on page 2 of the record →

Allegation investigated: Severe neglect resulting in death of resident. Resident sustained a fracture while in care. Resident's left in soiled clothing for a long period of time. Resident's room is unsanitary. Facility has a foul odor. Staff failed to meet resident's hygiene needs.

Read the state’s words on page 2 of the record →